MEDICARE: MS. JENNIFER SUSAN GREEN FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	4704144751	MI
2	363LF0000X	Family Nurse Practitioner	4704144751	MI

General Provider Information

NPI Number	:	1326339938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER SUSAN GREEN FNP-BC

Provider Business Mailing Address
First Line	:	28535 LAKE PARK DR W
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-4621
Country	:	US
Telephone Number	:	248-225-2826
Fax Number	:

Provider Business Practice Location Address
First Line	:	28535 LAKE PARK DR W
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-4621
Country	:	US
Telephone Number	:	248-225-2826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2011
Last Update Date	:	03/08/2024

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