Provider Demographics
NPI:1952717662
Name:GREEN, JASON LEE (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 JOHNSON DR
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-3333
Mailing Address - Country:US
Mailing Address - Phone:913-262-3937
Mailing Address - Fax:913-262-3942
Practice Address - Street 1:6120 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-3333
Practice Address - Country:US
Practice Address - Phone:913-262-3937
Practice Address - Fax:913-262-3942
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1979152W00000X
TX8506T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist