Provider Demographics
NPI:1396389615
Name:WRAY, JODI
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:
Last Name:WRAY
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 1:202 BOOTH ST #203
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53933
Mailing Address - Country:US
Mailing Address - Phone:920-763-2643
Mailing Address - Fax:
Practice Address - Street 1:202 BOOTH ST #202
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:WI
Practice Address - Zip Code:53933
Practice Address - Country:US
Practice Address - Phone:920-319-2884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider