Provider Demographics
NPI:1497421556
Name:GREEN, JADE ELISABETH
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:ELISABETH
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 POWDER SPRINGS ST APT 1104
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3695
Mailing Address - Country:US
Mailing Address - Phone:562-708-2036
Mailing Address - Fax:
Practice Address - Street 1:2001 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6442
Practice Address - Country:US
Practice Address - Phone:844-543-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician