Provider Demographics
NPI:1689467326
Name:GREGORY, JESSICA LYN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BELK ST
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-1813
Mailing Address - Country:US
Mailing Address - Phone:330-907-1705
Mailing Address - Fax:
Practice Address - Street 1:102 BELK ST
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1813
Practice Address - Country:US
Practice Address - Phone:330-907-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach