Provider Demographics
NPI:1659314581
Name:GREENE, JORDAN LOUIS (DC)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:LOUIS
Last Name:GREENE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-5403
Mailing Address - Country:US
Mailing Address - Phone:908-757-0377
Mailing Address - Fax:908-757-6484
Practice Address - Street 1:2202 PARK AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-5403
Practice Address - Country:US
Practice Address - Phone:908-757-0377
Practice Address - Fax:908-757-6484
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00414700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5485801Medicaid
NJ155964Medicare PIN