Provider Demographics
NPI:1235510017
Name:GRAY, JACQUELINE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NB GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2301
Mailing Address - Country:US
Mailing Address - Phone:586-690-4333
Mailing Address - Fax:586-783-2950
Practice Address - Street 1:100 NB GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2301
Practice Address - Country:US
Practice Address - Phone:586-783-2950
Practice Address - Fax:586-690-4333
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010979791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical