Provider Demographics
NPI:1588306898
Name:GREEN, JONATHAN ANDREW
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAI
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3317 W 4TH ST APT 16
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-5860
Mailing Address - Country:US
Mailing Address - Phone:601-964-1696
Mailing Address - Fax:
Practice Address - Street 1:1000 CHINABERRY DR STE 903
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2455
Practice Address - Country:US
Practice Address - Phone:318-459-6795
Practice Address - Fax:318-626-5429
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health