Provider Demographics
NPI:1639628407
Name:GREEN, JESSICA JASMINE (PNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JASMINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4687 POUCEY TRACT ROAD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059
Mailing Address - Country:US
Mailing Address - Phone:757-604-5446
Mailing Address - Fax:
Practice Address - Street 1:4687 POUCEY TRACT ROAD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059
Practice Address - Country:US
Practice Address - Phone:804-422-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173970363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics