Provider Demographics
NPI:1679563209
Name:FRAY, JENNIFER A (PSYD, HSPP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:FRAY
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 FOREST GROVE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3709
Mailing Address - Country:US
Mailing Address - Phone:260-485-6971
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041632A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200371000Medicaid
P47624Medicare UPIN
IN200371000Medicaid