Provider Demographics
NPI:1912635830
Name:GREEN, JORDYN
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:
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 1:4601 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2729
Mailing Address - Country:US
Mailing Address - Phone:323-234-4445
Mailing Address - Fax:323-682-0632
Practice Address - Street 1:4601 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2729
Practice Address - Country:US
Practice Address - Phone:323-234-4445
Practice Address - Fax:323-682-0632
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X, 390200000X
CA106H00000X
CAUNAVAILABLE106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program