Healthcare Provider Details

I. General information

NPI: 1144622382
Provider Name (Legal Business Name): JONATHAN GREEN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 EASTCHESTER RD
BRONX NY
10461-2301
US

IV. Provider business mailing address

51 BERKSHIRE PL
ALLENDALE NJ
07401-2005
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-3012
  • Fax:
Mailing address:
  • Phone: 518-729-6155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number624738
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number339165
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01036100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: