Provider Demographics
NPI:1467829192
Name:GREEN, JONATHAN MICHAEL (CNIM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:GREEN
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 SW ASH MEADOWS RD
Mailing Address - Street 2:113
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-4014
Mailing Address - Country:US
Mailing Address - Phone:301-335-4422
Mailing Address - Fax:
Practice Address - Street 1:13 S TEJON ST FL 5
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1513
Practice Address - Country:US
Practice Address - Phone:866-286-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2612246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic