Provider Demographics
NPI:1770701393
Name:GRAY, JACQUELINE (MA, MFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:JACKI
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, MFT
Mailing Address - Street 1:2960 CAMINO DIABLO
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3988
Mailing Address - Country:US
Mailing Address - Phone:925-932-3393
Mailing Address - Fax:925-370-7893
Practice Address - Street 1:2960 CAMINO DIABLO
Practice Address - Street 2:SUITE 200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3988
Practice Address - Country:US
Practice Address - Phone:925-932-3393
Practice Address - Fax:925-370-7893
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC21441106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist