Provider Demographics
NPI:1124156922
Name:GREEN, JENNIFER D (CST)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:GREEN
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:D
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7401 S. MAIN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:713-799-2300
Mailing Address - Fax:713-794-3395
Practice Address - Street 1:2635 BAKER RD.
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521
Practice Address - Country:US
Practice Address - Phone:281-837-8550
Practice Address - Fax:281-837-8709
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102511363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical