Provider Demographics
NPI:1447790100
Name:GREEN, JODY ALAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:ALAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1302
Mailing Address - Country:US
Mailing Address - Phone:515-564-8746
Mailing Address - Fax:515-564-8741
Practice Address - Street 1:730 3RD ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1302
Practice Address - Country:US
Practice Address - Phone:515-564-8746
Practice Address - Fax:515-564-8741
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0011972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer