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General NPI Number Information
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NPI Number | 1073064242
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Entity Type | Individual
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Provider Name | JENNIFER NICOLE GREEN NP-C
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Gender | Female
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Dates
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Enumeration Date | 10/21/2016
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Last Update Date | 01/04/2023
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Provider Practice Location Address
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Address Line | 2421 COUNTY ROAD 16
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City | LOUIN
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State | MS
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Zip | 39338-3230
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Country | US
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Telephone | 931-384-8212
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Fax |
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Provider Business Mailing Address
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Address Line | 500 W 190TH ST STE 400
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City | GARDENA
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State | CA
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Zip | 90248-4290
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 22027
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 903916
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License Number State | MS
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