Provider Demographics
NPI:1760779870
Name:GREEN, JEANNETTA LOUISE (LMT)
Entity Type:Individual
Prefix:
First Name:JEANNETTA
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1094
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76645-1094
Mailing Address - Country:US
Mailing Address - Phone:254-580-5399
Mailing Address - Fax:
Practice Address - Street 1:207 E ELM ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:TX
Practice Address - Zip Code:76645-3322
Practice Address - Country:US
Practice Address - Phone:254-580-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-09
Last Update Date:2011-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109236225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist