Provider Demographics
NPI:1508582727
Name:GREY, JACKSON ADONIS
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:ADONIS
Last Name:GREY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1294 18TH ST E
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-3680
Mailing Address - Country:US
Mailing Address - Phone:651-888-4462
Mailing Address - Fax:
Practice Address - Street 1:1294 18TH ST E
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-3680
Practice Address - Country:US
Practice Address - Phone:651-888-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)