Provider Demographics
NPI:1780108670
Name:GREEN, JESSICA J
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-1911
Mailing Address - Country:US
Mailing Address - Phone:618-554-4777
Mailing Address - Fax:
Practice Address - Street 1:3021 HICKORY ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1818
Practice Address - Country:US
Practice Address - Phone:314-345-5673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017026197235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist