Provider Demographics
NPI:1588968945
Name:GREEN, JE'DETTE ANGELIQUE (ANP-C)
Entity type:Individual
Prefix:
First Name:JE'DETTE
Middle Name:ANGELIQUE
Last Name:GREEN
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:KIKI
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP-C
Mailing Address - Street 1:PO BOX 90812
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99509-0812
Mailing Address - Country:US
Mailing Address - Phone:907-375-2025
Mailing Address - Fax:
Practice Address - Street 1:2925 DEBARR RD STE 199
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2959
Practice Address - Country:US
Practice Address - Phone:907-375-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily