Provider Demographics
NPI:1780673699
Name:GREEN, JEFFREY A (D C)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 ROSSMAN AVE
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:PA
Mailing Address - Zip Code:16232-1844
Mailing Address - Country:US
Mailing Address - Phone:814-797-2863
Mailing Address - Fax:814-797-2863
Practice Address - Street 1:108 ROSSMAN AVE
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:PA
Practice Address - Zip Code:16232-1844
Practice Address - Country:US
Practice Address - Phone:814-797-2863
Practice Address - Fax:814-797-2863
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004902L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA212200OtherUPMC HEALTH PLAN
PA0012742240004Medicaid
PA336136OtherPA BLUE SHIELD
PAU31233Medicare UPIN
PA212200OtherUPMC HEALTH PLAN