Healthcare Provider Details

I. General information

NPI: 1366973760
Provider Name (Legal Business Name): JUANDA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 11/21/2020
Certification Date: 11/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27260 NICOLAS RD APT B104
TEMECULA CA
92591-7357
US

IV. Provider business mailing address

40335 WINCHESTER RD STE E
TEMECULA CA
92591-5518
US

V. Phone/Fax

Practice location:
  • Phone: 951-587-6328
  • Fax:
Mailing address:
  • Phone: 951-587-6328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: