Provider Demographics
NPI:1770069684
Name:GREEN, JUSTIN JERMAINE (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JERMAINE
Last Name:GREEN
Suffix:
Gender:M
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 CLARICE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-4626
Mailing Address - Country:US
Mailing Address - Phone:901-830-9256
Mailing Address - Fax:
Practice Address - Street 1:4412 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6408
Practice Address - Country:US
Practice Address - Phone:901-830-9256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1268181744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty