Basic Information
| Provider Information | |||||||||
| NPI: | 1366636011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1377 SPRING GARDEN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | DE LEON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869855783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 305 CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321748181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866763130 | ||||||||
| FaxNumber: | 3866767572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 09/05/2007 | ||||||||
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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 | 225200000X | PTA19986 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.