Provider Demographics
NPI:1033931928
Name:GRAY, JESSICA LANE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LANE
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 1:109 KERR AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5270
Mailing Address - Country:US
Mailing Address - Phone:539-316-4616
Mailing Address - Fax:
Practice Address - Street 1:109 KERR AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5270
Practice Address - Country:US
Practice Address - Phone:539-316-4616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator