Provider Demographics
NPI:1952858144
Name:GRAY, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
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 1:39 PARK VALE AVE
Mailing Address - Street 2:APT. 2
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-2626
Mailing Address - Country:US
Mailing Address - Phone:401-864-1948
Mailing Address - Fax:
Practice Address - Street 1:45 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1208
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical