Provider Demographics
NPI:1578997847
Name:GREEN, JEREMY TODD
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:TODD
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 1:7137 SPRUCEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-4731
Mailing Address - Country:US
Mailing Address - Phone:702-327-7803
Mailing Address - Fax:
Practice Address - Street 1:3680 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3180
Practice Address - Country:US
Practice Address - Phone:702-869-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst