Provider Demographics
NPI:1063437044
Name:GRZEGOREK, JENNIFER L (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GRZEGOREK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572S HAGADORN RD 2E
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5385
Mailing Address - Country:US
Mailing Address - Phone:517-896-4231
Mailing Address - Fax:
Practice Address - Street 1:4572S HAGADORN RD 2E
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5385
Practice Address - Country:US
Practice Address - Phone:517-896-4231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012797103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680C31308OtherBLUE CROSS & BLUE SHIELD