Healthcare Provider Details

I. General information

NPI: 1811275795
Provider Name (Legal Business Name): JASON M. GREEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BROADWAY ST
GALENA IL
61036-1902
US

IV. Provider business mailing address

1736 HWY 80
CUBA CITY WI
53807-9708
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-0042
  • Fax:
Mailing address:
  • Phone: 563-209-8583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.011965
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: