Provider Demographics
NPI:1962658153
Name:GREEN, JEREMY BRENT
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRENT
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 HIGHWAY 278 W
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-8007
Mailing Address - Country:US
Mailing Address - Phone:870-451-9742
Mailing Address - Fax:
Practice Address - Street 1:1575 HIGHWAY 371 W
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-7598
Practice Address - Country:US
Practice Address - Phone:870-457-9742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health