Healthcare Provider Details

I. General information

NPI: 1740473792
Provider Name (Legal Business Name): JILDA S GREEN PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 11/10/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 ROOSEVELT BLVD
PHILADELPHIA PA
19124-2343
US

IV. Provider business mailing address

4641 ROOSEVELT BLVD
PHILADELPHIA PA
19124-2343
US

V. Phone/Fax

Practice location:
  • Phone: 215-831-2896
  • Fax: 215-831-2929
Mailing address:
  • Phone: 215-831-2896
  • Fax: 215-831-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPS016428
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016428
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: