Provider Demographics
NPI:1578816138
Name:GREEN, JACQUELINE MARIE (MS, RN, APN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, RN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PATERSON ST
Mailing Address - Street 2:CLINICAL ACADEMIC BUILDING SUITE 6176
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1962
Mailing Address - Country:US
Mailing Address - Phone:732-235-6423
Mailing Address - Fax:732-236-6530
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:CLINICAL ACADEMIC BUILDING SUITE 6176
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-6423
Practice Address - Fax:732-236-6530
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00007600364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health