Provider Demographics
NPI:1770293102
Name:GRAY, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
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 1:12160 IVAKOTA CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-8652
Mailing Address - Country:US
Mailing Address - Phone:703-853-9742
Mailing Address - Fax:
Practice Address - Street 1:7700 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4301
Practice Address - Country:US
Practice Address - Phone:804-747-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program