Basic Information
| Provider Information | |||||||||
| NPI: | 1457333551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BALDWIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849113 | ||||||||
| FaxNumber: | 7043849118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 MATTHEWS TOWNSHIP PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281055402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043846901 | ||||||||
| FaxNumber: | 7043846902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 102661 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.