Provider Demographics
NPI:1235641309
Name:GRAY, JATIQUALYN DEJENAE
Entity Type:Individual
Prefix:MISS
First Name:JATIQUALYN
Middle Name:DEJENAE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 LOONEY ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-2107
Mailing Address - Country:US
Mailing Address - Phone:318-946-1085
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-603-4696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator