Provider Demographics
NPI:1982129755
Name:GREKU, JENNA NICOLE (MED, EDS,)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:GREKU
Suffix:
Gender:F
Credentials:MED, EDS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 CHESTNUT RDG
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-8800
Mailing Address - Country:US
Mailing Address - Phone:330-205-7941
Mailing Address - Fax:
Practice Address - Street 1:1490 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3806
Practice Address - Country:US
Practice Address - Phone:330-829-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3256265103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGREK177Medicaid