Provider Demographics
NPI:1992382808
Name:GREEN, JADE ALEXIS (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:JADE
Middle Name:ALEXIS
Last Name:GREEN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26300 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2019
Mailing Address - Country:US
Mailing Address - Phone:313-388-4630
Mailing Address - Fax:
Practice Address - Street 1:26300 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2019
Practice Address - Country:US
Practice Address - Phone:313-388-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MI6851114352104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty