Basic Information
| Provider Information | |||||||||
| NPI: | 1215352901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 WELLNESS DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486702000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448321956 | ||||||||
| FaxNumber: | 9896335241 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E WARWICK DR STE D | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894665486 | ||||||||
| FaxNumber: | 9894665023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 5101021250 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.