Provider Demographics
NPI:1124066725
Name:GRAY, JACQUELINE MARY (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARY
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1173
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-1173
Mailing Address - Country:US
Mailing Address - Phone:562-493-0933
Mailing Address - Fax:562-493-0922
Practice Address - Street 1:5212 KATELLA AVE
Practice Address - Street 2:SUITE #202
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2828
Practice Address - Country:US
Practice Address - Phone:562-493-0933
Practice Address - Fax:562-493-0922
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11186103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA542200PL111861OtherBLUE SHIELD PROVIDER
CACP11186AMedicare ID - Type Unspecified
CA542200PL111861OtherBLUE SHIELD PROVIDER