Provider Demographics
NPI:1386104834
Name:GREENE, JONATHAN LEO (MSW, LMSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEO
Last Name:GREENE
Suffix:
Gender:M
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3253 YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7561
Mailing Address - Country:US
Mailing Address - Phone:443-562-4149
Mailing Address - Fax:
Practice Address - Street 1:2300 GARRISON BLVD STE 104
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2308
Practice Address - Country:US
Practice Address - Phone:410-233-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker