Healthcare Provider Details

I. General information

NPI: 1205489754
Provider Name (Legal Business Name): JESSICA GREEN MSN, RN-BC, AGCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 N MERIDIAN ST
CARMEL IN
46032-4656
US

IV. Provider business mailing address

1686 N VISTA DR
INDIANAPOLIS IN
46280-1799
US

V. Phone/Fax

Practice location:
  • Phone: 317-688-3409
  • Fax:
Mailing address:
  • Phone: 812-239-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number28172147A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number28172147A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: