Healthcare Provider Details

I. General information

NPI: 1134981996
Provider Name (Legal Business Name): JESSICA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CONCORD AVE STE 185
CONCORD CA
94520-4915
US

IV. Provider business mailing address

1219 NE 108TH AVE
VANCOUVER WA
98664-4348
US

V. Phone/Fax

Practice location:
  • Phone: 360-241-7060
  • Fax:
Mailing address:
  • Phone: 360-241-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: