Provider Demographics
NPI:1588205249
Name:GREEN, JENNIFER MOODY (LVN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MOODY
Last Name:GREEN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEA
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16418 BROOKFORD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77059-4707
Mailing Address - Country:US
Mailing Address - Phone:281-825-2799
Mailing Address - Fax:
Practice Address - Street 1:16418 BROOKFORD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77059-4707
Practice Address - Country:US
Practice Address - Phone:281-825-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336799164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse