Provider Demographics
NPI:1992515530
Name:GREEN, IMANI JANAE
Entity type:Individual
Prefix:MS
First Name:IMANI
Middle Name:JANAE
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 1:3444 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5331
Mailing Address - Country:US
Mailing Address - Phone:601-786-8091
Mailing Address - Fax:
Practice Address - Street 1:3444 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5331
Practice Address - Country:US
Practice Address - Phone:601-786-8091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-07
Last Update Date:2025-02-07
Deactivation Date:2025-01-22
Deactivation Code:
Reactivation Date:2025-02-03
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health