MEDICARE: MS. JENNIFER GREEN LM, CPM

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	171W00000X	Contractor	0129-000104	VA

General Provider Information

NPI Number	:	1174921357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER GREEN LM, CPM

Provider Business Mailing Address
First Line	:	2253 CALVERT ST
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1739
Country	:	US
Telephone Number	:	757-339-4315
Fax Number	:	757-313-4596

Provider Business Practice Location Address
First Line	:	2253 CALVERT ST
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1739
Country	:	US
Telephone Number	:	757-339-4315
Fax Number	:	757-313-4596

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

Provider Enumeration Date	:	12/20/2014
Last Update Date	:	12/20/2014

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