=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972193886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSI GREEN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2021
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12400 N MERIDIAN ST STE 100
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-559-3320
-----------------------------------------------------
Fax | 317-559-3321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2163 S NOELTING WAY
-----------------------------------------------------
City | NEW PALESTINE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46163-9289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-313-1260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | 71010851A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------