Basic Information
| Provider Information | |||||||||
| NPI: | 1285267583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JBSA FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105399582 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109164141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2020 | ||||||||
| LastUpdateDate: | 01/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 206364 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.