Healthcare Provider Details

I. General information

NPI: 1124904529
Provider Name (Legal Business Name): JASON DWIN GREEN ED.D,HON. D.COUNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 GRANDMOTHER HAT ST
NORTH LAS VEGAS NV
89081-6467
US

IV. Provider business mailing address

5616 GRANDMOTHER HAT ST
NORTH LAS VEGAS NV
89081-6467
US

V. Phone/Fax

Practice location:
  • Phone: 310-597-0282
  • Fax:
Mailing address:
  • Phone: 310-597-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number18090
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: