Provider Demographics
NPI:1770113607
Name:GREEN, JENNIFER (BCBS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:BCBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59053
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39284-9053
Mailing Address - Country:US
Mailing Address - Phone:769-226-6232
Mailing Address - Fax:
Practice Address - Street 1:21 VALENCIA CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4725
Practice Address - Country:US
Practice Address - Phone:769-226-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst