1346628484 NPI number — MRS. JESSICA NICHOLE GREENE D.O.

Table of content: MRS. JESSICA NICHOLE GREENE D.O. (NPI 1346628484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346628484 NPI number — MRS. JESSICA NICHOLE GREENE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
JESSICA
Provider Middle Name:
NICHOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
JESSICA
Provider Other Middle Name:
NICHOLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346628484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 SGT ED HOLCOMB BLVD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-1990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-756-8331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 W GRAND AVE
Provider Second Line Business Practice Location Address:
MEDICAL EDUCATION DEPARTMENT
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45405-4720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-723-3245
Provider Business Practice Location Address Fax Number:
937-723-5017
Provider Enumeration Date:
05/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  S1110 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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