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General NPI Number Information
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NPI Number | 1871088302
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Entity Type | Individual
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Provider Name | JALISSA GREEN
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Gender | Female
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Dates
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Enumeration Date | 06/27/2018
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Last Update Date | 09/07/2018
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Provider Practice Location Address
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Address Line | 4019 PARLIAMENT DR
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City | ALEXANDRIA
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State | LA
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Zip | 71303
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Country | US
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Telephone | 318-308-9748
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Fax |
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Provider Business Mailing Address
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Address Line | 4500 QUEEN ELIZABETH CT APT 172
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City | ALEXANDRIA
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State | LA
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Zip | 71303-2757
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Country | US
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Telephone | 337-718-1539
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-18-31291
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License Number State |
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