Provider Demographics
NPI:1861623308
Name:GREEN, JENNIFER BROOKE (NP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BROOKE
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 REED RD STE 104
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-6310
Mailing Address - Country:US
Mailing Address - Phone:706-278-1622
Mailing Address - Fax:706-272-6445
Practice Address - Street 1:475 REED RD STE 104
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-6310
Practice Address - Country:US
Practice Address - Phone:706-278-1622
Practice Address - Fax:706-272-6445
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN115738363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134778AMedicaid
GA01881320OtherAMERIGROUP
GAP01156288OtherRR MEDICARE
GA804217OtherWELLCARE
GA003134778AMedicaid