Provider Demographics
NPI:1104221811
Name:GREEN, JESSICA (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:843-857-0206
Practice Address - Street 1:1268 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-0703
Practice Address - Country:US
Practice Address - Phone:843-332-3422
Practice Address - Fax:843-332-3985
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6910101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1862Medicaid
SCSCS668OtherMEDICARE