Healthcare Provider Details

I. General information

NPI: 1407676596
Provider Name (Legal Business Name): JEFFREY GREENBAUM MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 11/26/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S. JACKSON ST
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 1983
WILSON WY
83014-1983
US

V. Phone/Fax

Practice location:
  • Phone: 307-690-3383
  • Fax:
Mailing address:
  • Phone: 307-690-3383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY GREENBAUM
Title or Position: MANAGER
Credential:
Phone: 307-690-3383