Provider Demographics
NPI:1467648428
Name:GREEN, JENNIFER J (PT)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25825 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3518
Mailing Address - Country:US
Mailing Address - Phone:310-517-2188
Mailing Address - Fax:310-517-2124
Practice Address - Street 1:25825 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:310-517-2188
Practice Address - Fax:310-517-2124
Is Sole Proprietor?:No
Enumeration Date:2007-09-23
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33699OtherPHYSICAL THERAPIST