Healthcare Provider Details

I. General information

NPI: 1235366337
Provider Name (Legal Business Name): JENNIFER GREEN LUSK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JENNIFER SHAND GREEN

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W, LA VETA
ORANGE CA
92868
US

IV. Provider business mailing address

1201 W, LA VETA
ORANGE CA
92868
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-8826
  • Fax:
Mailing address:
  • Phone: 714-509-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA108240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: