Provider Demographics
NPI:1558012047
Name:GREEN, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6728 S PERRY AVE # 3N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-3733
Mailing Address - Country:US
Mailing Address - Phone:773-617-3404
Mailing Address - Fax:
Practice Address - Street 1:6808 S PERRY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3758
Practice Address - Country:US
Practice Address - Phone:773-617-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG65043289292172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver