Provider Demographics
NPI:1518641471
Name:GREEN, JESSICA SHANTE (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHANTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S GEORGE MASON DR APT 714
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1864
Mailing Address - Country:US
Mailing Address - Phone:706-329-7050
Mailing Address - Fax:
Practice Address - Street 1:1208 E CHURCHVILLE RD STE 300
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3485
Practice Address - Country:US
Practice Address - Phone:410-893-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010482104100000X
VA0903003712104100000X
MD30282104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker