Provider Demographics
NPI:1093087868
Name:GRAY, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S PIONEER RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3800
Mailing Address - Country:US
Mailing Address - Phone:920-922-7776
Mailing Address - Fax:920-922-2938
Practice Address - Street 1:103 S PIONEER RD
Practice Address - Street 2:SUITE #100
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3800
Practice Address - Country:US
Practice Address - Phone:920-922-7776
Practice Address - Fax:920-922-2938
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1836-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant