=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366449316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY LEE GREEN JR. FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 POPE AVE MUNSON ARMY HEALTH CENTER (ATTN: MCXN-COD, MS. COTTON)
-----------------------------------------------------
City | FORT LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66027-2332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-684-6562
-----------------------------------------------------
Fax | 913-684-6208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6522 HEDGE LANE TER APT 206
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66226-4872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-584-3952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP30006651
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 45863
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------