Provider Demographics
NPI:1639788698
Name:GRAY, JASMINE C
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:C
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 1:1300 N VEL R PHILLIPS AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-4008
Mailing Address - Country:US
Mailing Address - Phone:141-455-1547
Mailing Address - Fax:414-551-5416
Practice Address - Street 1:1300 N VEL R PHILLIPS AVE APT 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-4008
Practice Address - Country:US
Practice Address - Phone:141-455-1541
Practice Address - Fax:414-551-5416
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI81-4909668Medicaid