Healthcare Provider Details

I. General information

NPI: 1346949781
Provider Name (Legal Business Name): JARDENA MARIE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 BEATY GROVE DR
TAMPA FL
33626-1602
US

IV. Provider business mailing address

2231 MEDINA AVE
COLUMBUS OH
43211-2277
US

V. Phone/Fax

Practice location:
  • Phone: 813-926-5454
  • Fax:
Mailing address:
  • Phone: 614-599-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: