Provider Demographics
NPI:1699444711
Name:GREEN, JACQUELINE (DPT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 BASSETT ST APT 415
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1024
Mailing Address - Country:US
Mailing Address - Phone:847-404-8067
Mailing Address - Fax:
Practice Address - Street 1:1000 W SOUTH BOULDER RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2752
Practice Address - Country:US
Practice Address - Phone:303-415-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0017804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist