Provider Demographics
NPI:1699247007
Name:GREEN, JAMIKA DANGERFIELD
Entity type:Individual
Prefix:
First Name:JAMIKA
Middle Name:DANGERFIELD
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 1:11954 PIA DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77044-1739
Mailing Address - Country:US
Mailing Address - Phone:346-907-7055
Mailing Address - Fax:
Practice Address - Street 1:11954 PIA DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77044-1739
Practice Address - Country:US
Practice Address - Phone:346-907-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-23
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
TX172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician