Healthcare Provider Details

I. General information

NPI: 1508781683
Provider Name (Legal Business Name): JACOB GREEN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 WESTCLIFF DR STE 203
NEWPORT BEACH CA
92660-5543
US

IV. Provider business mailing address

11856 FORTNEY DR
ANAHEIM CA
92804-6724
US

V. Phone/Fax

Practice location:
  • Phone: 949-299-0297
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: