Provider Demographics
NPI:1588658363
Name:GREEN, JENNIFER S (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-3637
Mailing Address - Country:US
Mailing Address - Phone:912-355-6615
Mailing Address - Fax:912-354-5970
Practice Address - Street 1:4425 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-3637
Practice Address - Country:US
Practice Address - Phone:912-355-6615
Practice Address - Fax:912-354-5970
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4605363AM0700X
GA004605363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA467115303AMedicaid
GA467115303AMedicaid
GAQ51662Medicare UPIN