Healthcare Provider Details

I. General information

NPI: 1154833747
Provider Name (Legal Business Name): JENNIFER GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 BEE CAVES RD STE G2
WEST LAKE HILLS TX
78746-5246
US

IV. Provider business mailing address

7620 CAYENNE LN
AUSTIN TX
78741-7531
US

V. Phone/Fax

Practice location:
  • Phone: 702-417-6511
  • Fax:
Mailing address:
  • Phone: 702-417-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01794
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: