Healthcare Provider Details

I. General information

NPI: 1346628484
Provider Name (Legal Business Name): JESSICA NICHOLE GREENE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA NICHOLE CLARK D.O.

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE MEDICAL EDUCATION DEPARTMENT
DAYTON OH
45405-4720
US

IV. Provider business mailing address

233 SGT ED HOLCOMB BLVD S
CONROE TX
77304-1990
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-3245
  • Fax: 937-723-5017
Mailing address:
  • Phone: 936-756-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberS1110
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: