Provider Demographics
NPI:1710008784
Name:GREGORY, JENNIFER S (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIGER
Other - Middle Name:
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-221-6699
Mailing Address - Fax:501-221-7752
Practice Address - Street 1:9500 KANIS RD STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6358
Practice Address - Country:US
Practice Address - Phone:501-224-6699
Practice Address - Fax:501-224-7752
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE6425174400000X
ARE-6425207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE6425OtherLICENSE
1710008784OtherINDIVIDUAL NPI
FG1992418OtherDEA