Provider Demographics
NPI:1578188256
Name:GREEN, JACOB IRVING (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:IRVING
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:IRVING
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9474 BASE LINE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5822
Mailing Address - Country:US
Mailing Address - Phone:909-987-3211
Mailing Address - Fax:909-987-0317
Practice Address - Street 1:9474 BASE LINE RD
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-5822
Practice Address - Country:US
Practice Address - Phone:909-987-3211
Practice Address - Fax:909-987-0317
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5897213E00000X
CAEL6961213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist