Provider Demographics
NPI:1710171699
Name:GREENLY, JASON OWEN (BA, MHP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:OWEN
Last Name:GREENLY
Suffix:
Gender:M
Credentials:BA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3652
Mailing Address - Country:US
Mailing Address - Phone:217-398-7785
Mailing Address - Fax:217-398-7787
Practice Address - Street 1:70 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3652
Practice Address - Country:US
Practice Address - Phone:217-398-7785
Practice Address - Fax:217-398-7787
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor