Provider Demographics
NPI:1902292220
Name:GREEN, JENNIFER ANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22314 SW MANDAN DR
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7371
Mailing Address - Country:US
Mailing Address - Phone:503-819-0459
Mailing Address - Fax:
Practice Address - Street 1:1174 MOLALLA AVE
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3770
Practice Address - Country:US
Practice Address - Phone:503-656-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5660124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist