Provider Demographics
NPI:1164874475
Name:GRAY, JASON (LADC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BULLET HILL RD STE 216
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4699
Mailing Address - Country:US
Mailing Address - Phone:203-673-1099
Mailing Address - Fax:
Practice Address - Street 1:33 BULLET HILL RD STE 216
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-4699
Practice Address - Country:US
Practice Address - Phone:203-673-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001368101YA0400X
NY28314101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1164874475Medicaid