Provider Demographics
NPI:1477206308
Name:GRAY, JENNIFER (PMHNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5146 BRIDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5070
Mailing Address - Country:US
Mailing Address - Phone:847-651-9233
Mailing Address - Fax:
Practice Address - Street 1:4580 WEAVER PKWY STE 102
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3864
Practice Address - Country:US
Practice Address - Phone:630-839-9199
Practice Address - Fax:630-839-9299
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.438802163WP0808X
IL209.025795363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health