Provider Demographics
NPI:1750319398
Name:GREENE, JONATHAN HENRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:HENRY
Last Name:GREENE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 S ROBERTSON BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1605
Mailing Address - Country:US
Mailing Address - Phone:310-657-2029
Mailing Address - Fax:310-289-8581
Practice Address - Street 1:864 S ROBERTSON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1605
Practice Address - Country:US
Practice Address - Phone:310-657-2029
Practice Address - Fax:310-289-8581
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8214103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical