Provider Demographics
NPI:1306404108
Name:REGAL, JENNASSY GRACE
Entity Type:Individual
Prefix:
First Name:JENNASSY
Middle Name:GRACE
Last Name:REGAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 KIMBERLIE CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5329
Mailing Address - Country:US
Mailing Address - Phone:907-349-4222
Mailing Address - Fax:907-349-4223
Practice Address - Street 1:2836 KIMBERLIE CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5329
Practice Address - Country:US
Practice Address - Phone:907-349-4222
Practice Address - Fax:907-349-4223
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician