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General NPI Number Information
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NPI Number | 1669239117
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Entity Type | Individual
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Provider Name | JORDAN MATTHEW GREEN
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Gender | Male
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Dates
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Enumeration Date | 03/01/2024
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Last Update Date | 03/01/2024
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Provider Practice Location Address
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Address Line | 201 S 2ND ST
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City | STILWELL
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State | OK
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Zip | 74960-3838
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Country | US
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Telephone | 918-696-7220
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Fax |
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Provider Business Mailing Address
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Address Line | 363 HIDDEN GLEN TRL
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City | KANSAS
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State | OK
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Zip | 74347-9393
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Country | US
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Telephone | 405-519-2228
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 180477
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License Number State | OK
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