Healthcare Provider Details

I. General information

NPI: 1699205674
Provider Name (Legal Business Name): JESSIKA REBEKKAH GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date: 07/06/2021
Reactivation Date: 04/22/2026

III. Provider practice location address

5776 SAINT AUGUSTINE RD
JACKSONVILLE FL
32207-8046
US

IV. Provider business mailing address

5776 SAINT AUGUSTINE RD
JACKSONVILLE FL
32207-8046
US

V. Phone/Fax

Practice location:
  • Phone: 904-448-4700
  • Fax: 904-488-4717
Mailing address:
  • Phone: 904-448-4700
  • Fax: 904-488-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number27483
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: