MEDICARE: MARCUS JERMAINE GREEN

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1932848025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS JERMAINE GREEN

Provider Business Mailing Address
First Line	:	1544 W 25TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-4282
Country	:	US
Telephone Number	:	904-616-2764
Fax Number	:

Provider Business Practice Location Address
First Line	:	1544 W 25TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-4282
Country	:	US
Telephone Number	:	904-616-2764
Fax Number	:

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

Provider Enumeration Date	:	05/27/2022
Last Update Date	:	05/27/2022

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