Healthcare Provider Details

I. General information

NPI: 1477481182
Provider Name (Legal Business Name): JONATHAN EDWARD GREEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 W 77TH STREET NORTH DR
INDIANAPOLIS IN
46260-3502
US

IV. Provider business mailing address

535 W 77TH STREET NORTH DR
INDIANAPOLIS IN
46260-3502
US

V. Phone/Fax

Practice location:
  • Phone: 773-203-8651
  • Fax:
Mailing address:
  • Phone: 773-203-8651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34012888A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: