Provider Demographics
NPI:1457883274
Name:GRAY, JACQUIS LESHAY (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUIS
Middle Name:LESHAY
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUIS
Other - Middle Name:LESHAY
Other - Last Name:HOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:26333 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26333 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-4574
Practice Address - Country:US
Practice Address - Phone:248-331-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant