Provider Demographics
NPI:1790659886
Name:GREEN, JACQUELINE A (CHW,CHWC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:CHW,CHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5727 GASTON AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4665
Mailing Address - Country:US
Mailing Address - Phone:972-571-5847
Mailing Address - Fax:
Practice Address - Street 1:5727 GASTON AVE APT 101
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-4665
Practice Address - Country:US
Practice Address - Phone:972-571-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX277368171400000X
TX171M00000X, 174H00000X
TX9166172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator