Provider Demographics
NPI:1548413354
Name:GREEN, JENNIFER (CPM, RM)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CPM, RM
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MCPHERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8520 BOXELDER DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8520 BOXELDER DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5785
Practice Address - Country:US
Practice Address - Phone:719-659-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CO0000172176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health