Provider Demographics
NPI:1780136556
Name:GREGAN, JENNIFER L
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GREGAN
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:PO BOX 20033
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25362-1033
Mailing Address - Country:US
Mailing Address - Phone:304-746-2918
Mailing Address - Fax:304-746-2919
Practice Address - Street 1:718 BIGLEY AVENUE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302
Practice Address - Country:US
Practice Address - Phone:304-746-2918
Practice Address - Fax:304-746-2919
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1083064695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9435000000Medicaid
WV9435000001Medicaid