Provider Demographics
NPI:1104463520
Name:GRAY, JACILYN NICOLE (ACMHC)
Entity type:Individual
Prefix:MS
First Name:JACILYN
Middle Name:NICOLE
Last Name:GRAY
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:MS
Other - First Name:JACQUE
Other - Middle Name:NICOLE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ACMHC
Mailing Address - Street 1:2466 GREEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-3134
Mailing Address - Country:US
Mailing Address - Phone:801-448-8570
Mailing Address - Fax:
Practice Address - Street 1:3280 W 3500 S STE E
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-2668
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11558782-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health