Provider Demographics
NPI:1255460101
Name:GRAY, JENNIFER LYNN (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31620 23RD AVENUE SOUTH
Mailing Address - Street 2:SUITE 318
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-653-0168
Mailing Address - Fax:
Practice Address - Street 1:31620 23RD AVENUE SOUTH
Practice Address - Street 2:SUITE 318
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003
Practice Address - Country:US
Practice Address - Phone:253-653-0168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007382103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist