Provider Demographics
NPI:1518501394
Name:GREEN, JACLYNN S (FNP)
Entity Type:Individual
Prefix:
First Name:JACLYNN
Middle Name:S
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2583 NW TIMBERCREEK CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4026
Mailing Address - Country:US
Mailing Address - Phone:561-504-0536
Mailing Address - Fax:
Practice Address - Street 1:800 MEADOWS RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2304
Practice Address - Country:US
Practice Address - Phone:561-955-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily