=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174921357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER GREEN LM, CPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2014
-----------------------------------------------------
Last Update Date | 12/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2253 CALVERT ST
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-339-4315
-----------------------------------------------------
Fax | 757-313-4596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2253 CALVERT ST
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-339-4315
-----------------------------------------------------
Fax | 757-313-4596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | 0129-000104
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------