Provider Demographics
NPI:1164756045
Name:GREGORY-LYLES, JENNIFER BROOKE (LCMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOKE
Last Name:GREGORY-LYLES
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BROOKE
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1490
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-1490
Mailing Address - Country:US
Mailing Address - Phone:828-262-3886
Mailing Address - Fax:
Practice Address - Street 1:1925 N BRIDGE ST STE 101
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2105
Practice Address - Country:US
Practice Address - Phone:368-357-3373
Practice Address - Fax:336-835-7301
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7499101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1164756045Medicaid