Provider Demographics
NPI:1245735497
Name:JENNINGS, GREGORY MICHAEL (APRN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 SHACKELFORD RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-4369
Mailing Address - Country:US
Mailing Address - Phone:314-830-5805
Mailing Address - Fax:314-830-5806
Practice Address - Street 1:8444 SUMMERLIN DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-3906
Practice Address - Country:US
Practice Address - Phone:720-577-5251
Practice Address - Fax:720-780-7057
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003488363LF0000X
IL209017407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209017407Medicaid