Provider Demographics
NPI:1043519895
Name:GREEN, JENNIFER NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 NE CUMULUS AVE., STE A
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-8862
Mailing Address - Country:US
Mailing Address - Phone:503-434-8286
Mailing Address - Fax:
Practice Address - Street 1:2435 NE CUMULUS AVE., STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8862
Practice Address - Country:US
Practice Address - Phone:503-434-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO 167350208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDO167350OtherMEDICAL LICENSE