Provider Demographics
NPI:1568678480
Name:GREEN, JODI S (MA, CCC-A, FAAA)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:S
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA, CCC-A, FAAA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:GENDREAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-A, FAAA
Mailing Address - Street 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-446-9191
Mailing Address - Fax:904-446-9189
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:SUITE 801
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-446-9191
Practice Address - Fax:904-446-9189
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1069231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCF641YMedicare PIN