MEDICARE: JOLENE M GREEN LCSW

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	1041C0700X	Clinical Social Worker	132116-3501	UT

General Provider Information

NPI Number	:	1942352695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLENE M GREEN LCSW

Provider Business Mailing Address
First Line	:	8160 HIGHLAND DR STE 206
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-7403
Country	:	US
Telephone Number	:	801-943-6582
Fax Number	:	801-733-4007

Provider Business Practice Location Address
First Line	:	8160 HIGHLAND DR STE 206
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-7403
Country	:	US
Telephone Number	:	801-943-6582
Fax Number	:	801-733-4007

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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