Provider Demographics
NPI:1053025791
Name:GREEN, JAMON LAQUENTIN
Entity type:Individual
Prefix:
First Name:JAMON
Middle Name:LAQUENTIN
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 CORPORATE CENTER DR STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7214
Mailing Address - Country:US
Mailing Address - Phone:770-728-3990
Mailing Address - Fax:470-481-6998
Practice Address - Street 1:240 CORPORATE CENTER DR STE B
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7214
Practice Address - Country:US
Practice Address - Phone:770-728-3990
Practice Address - Fax:470-481-6998
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program