Healthcare Provider Details

I. General information

NPI: 1750021341
Provider Name (Legal Business Name): JALEEL GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5246 BRITTANY DR
BATON ROUGE LA
70808-9136
US

IV. Provider business mailing address

200 CRESCENT CENTER PKWY
TUCKER GA
30084-7047
US

V. Phone/Fax

Practice location:
  • Phone: 225-757-4212
  • Fax:
Mailing address:
  • Phone: 404-365-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number111610
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: