Provider Demographics
NPI:1114357555
Name:GRAY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
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 1:2315 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:916-734-2011
Mailing Address - Fax:480-428-8593
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:480-668-5000
Practice Address - Fax:480-428-8593
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5297364SA2100X
CANP95021660363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care