Healthcare Provider Details

I. General information

NPI: 1790834109
Provider Name (Legal Business Name): GREGORY S. JURENEC PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9455 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3559
US

IV. Provider business mailing address

9120 W HAMPTON AVE SUITE 212
MILWAUKEE WI
53225-4960
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-6995
  • Fax:
Mailing address:
  • Phone: 414-464-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1593-057
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1153-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: