Provider Demographics
NPI:1639232903
Name:GREEN, JEAN (RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BEAMAN RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MA
Mailing Address - Zip Code:01541-1133
Mailing Address - Country:US
Mailing Address - Phone:508-393-1920
Mailing Address - Fax:
Practice Address - Street 1:30 SEVER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2194
Practice Address - Country:US
Practice Address - Phone:508-393-1920
Practice Address - Fax:508-393-0569
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA843133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALD 0054OtherBCBS PROVIDER ID
MA39419OtherHARVARD PILGRIM HEALTH
MA725391OtherTUFTS PROVIDER ID
MAGRMT 0083Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
MAGRMT 0146Medicare ID - Type UnspecifiedMEDICARE ID NUMBER