MEDICARE: JEANNE GREEN PT

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	2251P0200X	Pediatric Physical Therapist	3516	GA
2	225100000X	Physical Therapist	3516	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3516	OTHER	GA	GEORGIA PT LICENSE
3	10040357	OTHER	GA	AMERIGROUP NUMBER
4	321854	OTHER	GA	WELLCARE NUMBER
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922168707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNE GREEN PT

Provider Business Mailing Address
First Line	:	503 RIVER CLUB DR
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-7792
Country	:	US
Telephone Number	:	404-861-0031
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 RIVER CLUB DRIVE
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-7792
Country	:	US
Telephone Number	:	404-861-0031
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	01/15/2026

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Directions to “ JEANNE GREEN PT” Practice Location

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