Provider Demographics
NPI:1750911897
Name:GREENWOOD, JESSICA ANN (MS)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANN
Last Name:GREENWOOD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 SWEEPING VINE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-6346
Mailing Address - Country:US
Mailing Address - Phone:661-607-9072
Mailing Address - Fax:
Practice Address - Street 1:1058 SWEEPING VINE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-6346
Practice Address - Country:US
Practice Address - Phone:661-607-9072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 2472E0500X
NV170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No170300000XOther Service ProvidersGenetic Counselor, MS