Provider Demographics
NPI:1235414350
Name:GRAY, JORDAN ROBERT (PRO COUNSELOR)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:ROBERT
Last Name:GRAY
Suffix:
Gender:M
Credentials:PRO COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:801-373-0639
Practice Address - Street 1:151 S UNIVERSITY AVE STE 1500
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7903342-6009101YP2500X
UT7903342-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional