Provider Demographics
NPI:1649253527
Name:GRAY, JENNIFER JANE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-1177
Mailing Address - Country:US
Mailing Address - Phone:270-783-3573
Mailing Address - Fax:207-783-4081
Practice Address - Street 1:225 NATCHEZ TRACE AVENUE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-783-3573
Practice Address - Fax:270-783-4081
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64019961Medicaid
KYH33504Medicare UPIN
KY64019961Medicaid