MEDICARE: JILLIAN GREENE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY30737	CA

General Provider Information

NPI Number	:	1164977054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN GREENE PSYD

Provider Business Mailing Address
First Line	:	177 S MANSFIELD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3018
Country	:	US
Telephone Number	:	323-821-8194
Fax Number	:

Provider Business Practice Location Address
First Line	:	177 S MANSFIELD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3018
Country	:	US
Telephone Number	:	323-821-8194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2016
Last Update Date	:	01/07/2026

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