Healthcare Provider Details

I. General information

NPI: 1245735497
Provider Name (Legal Business Name): GREGORY MICHAEL JENNINGS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8444 SUMMERLIN DR
LONGMONT CO
80503-3906
US

IV. Provider business mailing address

1120 SHACKELFORD RD
FLORISSANT MO
63031-4369
US

V. Phone/Fax

Practice location:
  • Phone: 720-577-5251
  • Fax: 720-780-7057
Mailing address:
  • Phone: 314-830-5805
  • Fax: 314-830-5806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018003488
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017407
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: