Provider Demographics
NPI:1114364908
Name:RAY, JESSICA DAWN (DC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:RAY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W WHITE ST
Mailing Address - Street 2:
Mailing Address - City:MILLSTADT
Mailing Address - State:IL
Mailing Address - Zip Code:62260-1362
Mailing Address - Country:US
Mailing Address - Phone:618-401-9591
Mailing Address - Fax:
Practice Address - Street 1:3412 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3702
Practice Address - Country:US
Practice Address - Phone:618-876-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor