Provider Demographics
NPI:1669040879
Name:GRAY, JESSICA (LAC DAC, MSAC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LAC DAC, MSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19820 N 7TH ST STE 135
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-1698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19820 N 7TH ST STE 135
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-1698
Practice Address - Country:US
Practice Address - Phone:480-744-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
AZLAC-010748171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist