Provider Demographics
NPI:1851015606
Name:GREEN, JAKE (MA INTERN)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 FRANKLIN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-2020
Mailing Address - Country:US
Mailing Address - Phone:413-531-6036
Mailing Address - Fax:
Practice Address - Street 1:607 NORTH AVE BLDG 15
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1322
Practice Address - Country:US
Practice Address - Phone:781-395-0457
Practice Address - Fax:781-395-0198
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor