Healthcare Provider Details

I. General information

NPI: 1467648428
Provider Name (Legal Business Name): JENNIFER J GREEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2007
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25825 VERMONT AVE
HARBOR CITY CA
90710-3518
US

IV. Provider business mailing address

25825 VERMONT AVE
HARBOR CITY CA
90710-3518
US

V. Phone/Fax

Practice location:
  • Phone: 310-517-2188
  • Fax: 310-517-2124
Mailing address:
  • Phone: 310-517-2188
  • Fax: 310-517-2124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT33699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: