MEDICARE: MRS. JESSICA LEE GREEN FNP

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	363LF0000X	Family Nurse Practitioner	36407	TN

General Provider Information

NPI Number	:	1871334938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA LEE GREEN FNP

Provider Business Mailing Address
First Line	:	106 FERRELL AVE STE 5
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2371
Country	:	US
Telephone Number	:	423-239-0099
Fax Number	:	423-239-0273

Provider Business Practice Location Address
First Line	:	106 FERRELL AVE STE 5
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2371
Country	:	US
Telephone Number	:	423-239-0099
Fax Number	:

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

Provider Enumeration Date	:	06/03/2024
Last Update Date	:	06/03/2024

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