Provider Demographics
NPI:1730560459
Name:GREEN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:CADDO
Mailing Address - State:OK
Mailing Address - Zip Code:74729-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:CADDO
Practice Address - State:OK
Practice Address - Zip Code:74729-1111
Practice Address - Country:US
Practice Address - Phone:580-230-8945
Practice Address - Fax:918-465-0301
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator