Provider Demographics
NPI:1194558411
Name:GREEN, JEAN LOUISE
Entity type:Individual
Prefix:
First Name:JEAN LOUISE
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 1:921 AUTUMN LN UNIT 217
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-8514
Mailing Address - Country:US
Mailing Address - Phone:530-966-5254
Mailing Address - Fax:
Practice Address - Street 1:921 AUTUMN LN UNIT 217
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-8514
Practice Address - Country:US
Practice Address - Phone:530-966-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61465720225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist