Healthcare Provider Details

I. General information

NPI: 1790298644
Provider Name (Legal Business Name): JESSE GREENE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 5TH AVE N
ST PETERSBURG FL
33713-7521
US

IV. Provider business mailing address

3840 5TH AVE N
ST PETERSBURG FL
33713-7521
US

V. Phone/Fax

Practice location:
  • Phone: 727-367-2273
  • Fax:
Mailing address:
  • Phone: 727-367-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: