Provider Demographics
NPI:1811300510
Name:GREEN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 ANORAK ST
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-9543
Mailing Address - Country:US
Mailing Address - Phone:321-266-5014
Mailing Address - Fax:833-973-2664
Practice Address - Street 1:1223 DANIELS RD STE 302
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3835
Practice Address - Country:US
Practice Address - Phone:689-240-7945
Practice Address - Fax:833-973-2664
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9303454163WP0808X
FLARNP9303454363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health