Provider Demographics
NPI:1396000535
Name:GREGORY, JACQUETTA DENISE (LCSWA)
Entity Type:Individual
Prefix:MS
First Name:JACQUETTA
Middle Name:DENISE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1408
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27906-1408
Mailing Address - Country:US
Mailing Address - Phone:252-334-1536
Mailing Address - Fax:252-334-1598
Practice Address - Street 1:1023 US HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9070
Practice Address - Country:US
Practice Address - Phone:252-334-1536
Practice Address - Fax:252-334-1598
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0066481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical