MEDICARE: JASON THOMAS GREEN M.S.

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NOT VALID	OTHER		NOT VALID

General Provider Information

NPI Number	:	1770896979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON THOMAS GREEN M.S.

Provider Business Mailing Address
First Line	:	1401 N MICHAEL WAY
Second Line	:	#G133
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-1491
Country	:	US
Telephone Number	:	702-287-0218
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 N MICHAEL WAY
Second Line	:	#G133
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-1491
Country	:	US
Telephone Number	:	702-287-0218
Fax Number	:

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

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	10/14/2013

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