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NPI Code Detail

MEDICARE: JACQUELINE GREEN MA

MEDICARE: JACQUELINE GREEN MA
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
1103T00000XPsychologist6361007978MI
2106S00000XBehavior Technician
3247200000XOther Technician
4103K00000XBehavior Analyst
5103T00000XPsychologist

General Provider Information

NPI Number : 1598116204
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELINE GREEN MA
Provider Business Mailing Address
First Line : 986 ALBERTA ST
Second Line :
City : FERNDALE
State : MI
Zip : 48220-1627
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 30821 BARRINGTON ST
Second Line :
City : MADISON HEIGHTS
State : MI
Zip : 48071-1871
Country : US
Telephone Number : 248-965-3916
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2016
Last Update Date : 10/09/2024

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