Provider Demographics
NPI:1346354297
Name:GRAY, JACQUELINE J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:J
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 MARTIN LUTHER KING DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107
Mailing Address - Country:US
Mailing Address - Phone:318-227-3350
Mailing Address - Fax:318-227-3350
Practice Address - Street 1:2300 HOSPITAL DR STE 420
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2166
Practice Address - Country:US
Practice Address - Phone:318-212-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075835208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2489258Medicaid