Basic Information
| Provider Information | |||||||||
| NPI: | 1609541127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 383 CORBIN CENTER DR | ||||||||
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| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407011895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262911 | ||||||||
| FaxNumber: | 6065262901 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEITCHFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427541425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702301729 | ||||||||
| FaxNumber: | 2702301750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 008373 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.