Provider Demographics
NPI:1811101405
Name:GREEN, JO BAXTER (PHD)
Entity type:Individual
Prefix:DR
First Name:JO
Middle Name:BAXTER
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2116
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-2116
Mailing Address - Country:US
Mailing Address - Phone:903-723-7706
Mailing Address - Fax:
Practice Address - Street 1:516 N SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-2840
Practice Address - Country:US
Practice Address - Phone:903-723-7706
Practice Address - Fax:903-723-7716
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16370101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1712572Medicaid