Healthcare Provider Details

I. General information

NPI: 1720893563
Provider Name (Legal Business Name): JENNA GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28303 DEQUINDRE RD STE 100
MADISON HEIGHTS MI
48071-3040
US

IV. Provider business mailing address

15483 ELDERWOOD ST
ROSEVILLE MI
48066-4035
US

V. Phone/Fax

Practice location:
  • Phone: 248-658-1116
  • Fax:
Mailing address:
  • Phone: 586-565-0907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: