Provider Demographics
NPI:1144847708
Name:GREEN, JAQUELINE R
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JAQUELINE
Other - Middle Name:R
Other - Last Name:DA COSTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JAQUELINE R BAURER
Mailing Address - Street 1:3067 E WARM SPRINGS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3750
Mailing Address - Country:US
Mailing Address - Phone:702-202-0000
Mailing Address - Fax:
Practice Address - Street 1:3067 E WARM SPRINGS RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3750
Practice Address - Country:US
Practice Address - Phone:702-202-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program