Provider Demographics
NPI:1588318794
Name:GREEN, JALISA (CMHC-RI)
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CMHC-RI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5789 CAPE HARBOUR DR STE 201
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-8607
Mailing Address - Country:US
Mailing Address - Phone:727-469-3329
Mailing Address - Fax:
Practice Address - Street 1:5789 CAPE HARBOUR DR STE 201
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-8607
Practice Address - Country:US
Practice Address - Phone:727-469-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health