Individual
JILL M GREENE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MA, BCBA
Contact information
Practice address
6075 N STAFFORD PL, BOISE, ID 83713-2074
(802) 233-6582
Mailing address
6075 N STAFFORD PL, BOISE, ID 83713-2074
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
1-03-1242
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
800548272-83713-0000
TRICARE
ID
Enumeration date
05/06/2010
Last updated
05/06/2010
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