Healthcare Provider Details

I. General information

NPI: 1033054457
Provider Name (Legal Business Name): JENNIFER NICOLE GREEN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 MIZPAH RD
LOCUST HILL VA
23092-9808
US

IV. Provider business mailing address

11313 FARM RD
SALUDA VA
23149-2853
US

V. Phone/Fax

Practice location:
  • Phone: 804-824-4748
  • Fax: 804-824-4748
Mailing address:
  • Phone: 276-232-0155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606099
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: