Provider Demographics
NPI:1659559672
Name:GREEN, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13344 COMMUNITY RD APT 13
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-4782
Mailing Address - Country:US
Mailing Address - Phone:858-748-5224
Mailing Address - Fax:
Practice Address - Street 1:13344 COMMUNITY RD APT 13
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-4782
Practice Address - Country:US
Practice Address - Phone:858-748-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health