MEDICARE: JILLIAN GREENE PSYCHOLOGIST A PROFESSIONAL CORPORATION

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	103TC0700X	Clinical Psychologist
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1750933354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JILLIAN GREENE PSYCHOLOGIST A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	177 S MANSFIELD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3018
Country	:	US
Telephone Number	:	323-821-8194
Fax Number	:

Provider Business Practice Location Address
First Line	:	177 S MANSFIELD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3018
Country	:	US
Telephone Number	:	323-821-8194
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JILLIAN GREENE
Credential	:	PSY.D.
Telephone Number	:	323-821-8194

Provider Enumeration Date	:	07/12/2019
Last Update Date	:	02/25/2026

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