Provider Demographics
NPI:1629577234
Name:GRAY, JILL JOAN
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:JOAN
Last Name:GRAY
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 1:4443 HANOVER PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-8604
Mailing Address - Country:US
Mailing Address - Phone:727-481-6557
Mailing Address - Fax:
Practice Address - Street 1:6620 SOUTHPOINT DR S STE 450-J
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0901
Practice Address - Country:US
Practice Address - Phone:904-990-3955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12779101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health