Provider Demographics
NPI:1881185585
Name:GREGORY, JESSICA CLAIRE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CLAIRE
Last Name:GREGORY
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 1:101 PEACEFUL LN
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1007
Mailing Address - Country:US
Mailing Address - Phone:210-248-9077
Mailing Address - Fax:210-945-8489
Practice Address - Street 1:101 PEACEFUL LN
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-1007
Practice Address - Country:US
Practice Address - Phone:210-248-9077
Practice Address - Fax:210-945-8489
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71991101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional