Healthcare Provider Details

I. General information

NPI: 1063437044
Provider Name (Legal Business Name): JENNIFER L GRZEGOREK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4572S HAGADORN RD 2E
EAST LANSING MI
48823-5385
US

IV. Provider business mailing address

4572S HAGADORN RD 2E
EAST LANSING MI
48823-5385
US

V. Phone/Fax

Practice location:
  • Phone: 517-896-4231
  • Fax:
Mailing address:
  • Phone: 517-896-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012797
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: