Provider Demographics
NPI:1063068062
Name:GREEN, JAUCLYN RENEE (NP)
Entity type:Individual
Prefix:
First Name:JAUCLYN
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2884 SIMMONS RD
Mailing Address - Street 2:
Mailing Address - City:DRUMMONDS
Mailing Address - State:TN
Mailing Address - Zip Code:38023-4958
Mailing Address - Country:US
Mailing Address - Phone:901-230-0489
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25205363L00000X
MN6876363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner