Provider Demographics
NPI:1407621618
Name:GREEN, JOHN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14421 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-7743
Mailing Address - Country:US
Mailing Address - Phone:904-294-1764
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5753
Practice Address - Country:US
Practice Address - Phone:515-699-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1186771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical