Provider Demographics
NPI:1063200947
Name:RAY, JALEN
Entity type:Individual
Prefix:
First Name:JALEN
Middle Name:
Last Name:RAY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 W SWANN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2478
Mailing Address - Country:US
Mailing Address - Phone:813-492-7192
Mailing Address - Fax:
Practice Address - Street 1:2111 W SWANN AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2478
Practice Address - Country:US
Practice Address - Phone:813-251-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-430612106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician