Healthcare Provider Details

I. General information

NPI: 1194989590
Provider Name (Legal Business Name): JEFFREY C. GREGORY PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 24TH AVE S STE 204
GRAND FORKS ND
58201-6761
US

IV. Provider business mailing address

16872 S BIG CORMORANT RD
AUDUBON MN
56511-9480
US

V. Phone/Fax

Practice location:
  • Phone: 701-213-0426
  • Fax:
Mailing address:
  • Phone: 701-213-0426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number397
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number397
License Number StateND

VIII. Authorized Official

Name: DR. JEFFREY CHARLES GREGORY
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 701-213-0426