Provider Demographics
NPI:1649075359
Name:GREEN, JENNIFER RENEE (AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-9231
Mailing Address - Country:US
Mailing Address - Phone:817-343-9027
Mailing Address - Fax:
Practice Address - Street 1:3886 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5219
Practice Address - Country:US
Practice Address - Phone:910-989-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5021912363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology