Provider Demographics
NPI:1063207553
Name:GRAY, JEANINE LEE
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:LEE
Last Name:GRAY
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 1:308 SANTA ROSA AVE APT SUITE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4910
Mailing Address - Country:US
Mailing Address - Phone:707-362-0941
Mailing Address - Fax:
Practice Address - Street 1:983 SONOMA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4818
Practice Address - Country:US
Practice Address - Phone:707-362-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker