Basic Information
| Provider Information | |||||||||
| NPI: | 1033507363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWPORT CENTER DR | ||||||||
| Address2: | #213 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926607501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496441322 | ||||||||
| FaxNumber: | 9496440316 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N EUCLID ST | ||||||||
| Address2: | STE 680 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928015506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147800010 | ||||||||
| FaxNumber: | 7147800050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2015 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 41967 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | CB228642 | 01 | CA | MEDICARE PTAN | OTHER |