Provider Demographics
NPI:1295339216
Name:GREGORY, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 SSW LOOP 323 STE 107
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9237
Mailing Address - Country:US
Mailing Address - Phone:903-330-1536
Mailing Address - Fax:903-470-7328
Practice Address - Street 1:3334 SSW LOOP 323 STE 107
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9237
Practice Address - Country:US
Practice Address - Phone:903-330-1536
Practice Address - Fax:903-470-7328
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62622101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health