Healthcare Provider Details

I. General information

NPI: 1649570219
Provider Name (Legal Business Name): JENNIFER LOUISE GREEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S LAKE PARK AVE STE 1103
HOBART IN
46342-6641
US

IV. Provider business mailing address

1600 S LAKE PARK AVE STE 1103
HOBART IN
46342-6641
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-6448
  • Fax: 219-947-6839
Mailing address:
  • Phone: 219-947-6448
  • Fax: 219-947-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003567A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: