Provider Demographics
NPI:1578188256
Name:GREEN, JACOB IRVING (DPM)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:IRVING
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:IRVING
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1680 CHAMBERS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3655
Mailing Address - Country:US
Mailing Address - Phone:541-683-3351
Mailing Address - Fax:541-683-6440
Practice Address - Street 1:1680 CHAMBERS ST STE 201
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3655
Practice Address - Country:US
Practice Address - Phone:541-683-3351
Practice Address - Fax:541-683-6440
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP219527213ES0103X
CAE5897213E00000X
CAEL6961213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist