Healthcare Provider Details

I. General information

NPI: 1033507363
Provider Name (Legal Business Name): JENNIFER GREENE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N EUCLID ST STE 680
ANAHEIM CA
92801-5506
US

IV. Provider business mailing address

200 NEWPORT CENTER DR #213
NEWPORT BEACH CA
92660-7501
US

V. Phone/Fax

Practice location:
  • Phone: 714-780-0010
  • Fax: 714-780-0050
Mailing address:
  • Phone: 949-644-1322
  • Fax: 949-644-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 41967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: