MEDICARE: JACQUELINE A GREEN CHW,CHWC

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	171400000X	Health & Wellness Coach	277368	TX
2	171M00000X	Case Manager/Care Coordinator		TX
3	174H00000X	Health Educator		TX
4	172V00000X	Community Health Worker	9166	TX

General Provider Information

NPI Number	:	1790659886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE A GREEN CHW,CHWC

Provider Business Mailing Address
First Line	:	5727 GASTON AVE APT 101
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-4665
Country	:	US
Telephone Number	:	972-571-5847
Fax Number	:

Provider Business Practice Location Address
First Line	:	5727 GASTON AVE APT 101
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-4665
Country	:	US
Telephone Number	:	972-571-5847
Fax Number	:

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

Provider Enumeration Date	:	10/01/2025
Last Update Date	:	10/01/2025

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