Healthcare Provider Details

I. General information

NPI: 1780098244
Provider Name (Legal Business Name): JEFFREY GREEN MPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MERRIMACK ST
LOWELL MA
01854-3906
US

IV. Provider business mailing address

205 WALDEN ST APT. 4T
CAMBRIDGE MA
02140-3507
US

V. Phone/Fax

Practice location:
  • Phone: 978-454-2997
  • Fax:
Mailing address:
  • Phone: 617-939-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: