Provider Demographics
NPI:1366973760
Name:GREEN, JUANDA
Entity type:Individual
Prefix:
First Name:JUANDA
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 1:40335 WINCHESTER RD STE E
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5518
Mailing Address - Country:US
Mailing Address - Phone:951-587-6328
Mailing Address - Fax:
Practice Address - Street 1:27260 NICOLAS RD APT B104
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-7357
Practice Address - Country:US
Practice Address - Phone:951-587-6328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120593106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist