Basic Information
| Provider Information | |||||||||
| NPI: | 1104221811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 N IRBY ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295012808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436679414 | ||||||||
| FaxNumber: | 8436671362 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291022925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034334321 | ||||||||
| FaxNumber: | 8034330075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2014 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6910 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 570604046 | 05 | SC | MEDICAID |