Provider Demographics
NPI:1447791397
Name:GREEN, JESSE (PT, DPT, LMT, CSCS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT, DPT, LMT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 W 101ST ST APT 65
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4716
Mailing Address - Country:US
Mailing Address - Phone:917-648-1949
Mailing Address - Fax:
Practice Address - Street 1:4 W 101ST ST APT 65
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4716
Practice Address - Country:US
Practice Address - Phone:212-604-1316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-12
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041313-1225100000X
NY041313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist