Provider Demographics
NPI:1538462197
Name:GRAY, JODY
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0719
Mailing Address - Country:US
Mailing Address - Phone:509-837-1602
Mailing Address - Fax:509-837-4908
Practice Address - Street 1:12 S 8TH ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3020
Practice Address - Country:US
Practice Address - Phone:509-454-4143
Practice Address - Fax:509-454-3651
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60202580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8899381OtherMEDICARE PTAN