Provider Demographics
NPI:1063595734
Name:GRADY, JENNIFER LEA (LPC-MHSP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEA
Last Name:GRADY
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 ROGOSIN DR STE 4
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2965
Mailing Address - Country:US
Mailing Address - Phone:423-542-9900
Mailing Address - Fax:423-543-0900
Practice Address - Street 1:204 ROGOSIN DR STE 4
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2965
Practice Address - Country:US
Practice Address - Phone:423-542-9900
Practice Address - Fax:423-543-0900
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000002421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517520Medicaid