Provider Demographics
NPI:1639405061
Name:GRAY, JACK D (FNP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:GRAY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 BON AIRE AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-4464
Mailing Address - Country:US
Mailing Address - Phone:361-648-7535
Mailing Address - Fax:
Practice Address - Street 1:4504 N. LAURENT ST.
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901
Practice Address - Country:US
Practice Address - Phone:361-573-9999
Practice Address - Fax:361-573-9998
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily