Provider Demographics
NPI:1942352695
Name:GREEN, JOLENE M (LCSW)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 HIGHLAND DR STE 206
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-7403
Mailing Address - Country:US
Mailing Address - Phone:801-943-6582
Mailing Address - Fax:801-733-4007
Practice Address - Street 1:8160 HIGHLAND DR STE 206
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-7403
Practice Address - Country:US
Practice Address - Phone:801-943-6582
Practice Address - Fax:801-733-4007
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT132116-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical