Provider Demographics
NPI:1649288804
Name:GREGORY, JASON ROBIN (LPA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ROBIN
Last Name:GREGORY
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 DEVONSHIRE PL
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4593
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:380 SUWANNEE TRAIL STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-782-5927
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid
KY30604011Medicaid