Provider Demographics
NPI:1801601653
Name:GREEN, JASMINE SHANETTE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:SHANETTE
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 1:3609 ORMONDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AYDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28513-7035
Mailing Address - Country:US
Mailing Address - Phone:252-531-5682
Mailing Address - Fax:
Practice Address - Street 1:2902 N HERRITAGE ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1580
Practice Address - Country:US
Practice Address - Phone:252-686-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health