Provider Demographics
NPI:1366449316
Name:GREEN, JERRY LEE JR (FNP)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 HEDGE LANE TER
Mailing Address - Street 2:APT 206
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-4872
Mailing Address - Country:US
Mailing Address - Phone:360-584-3952
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:MUNSON ARMY HEALTH CENTER (ATTN: MCXN-COD, MS. COTTON)
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6562
Practice Address - Fax:913-684-6208
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006651363LF0000X
KS45863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily