Provider Demographics
NPI:1124124045
Name:GRAY, JILL MAVEN (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:MAVEN
Last Name:GRAY
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LP
Mailing Address - Street 1:4201 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4728
Mailing Address - Country:US
Mailing Address - Phone:952-933-8900
Mailing Address - Fax:952-945-9536
Practice Address - Street 1:4201 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4728
Practice Address - Country:US
Practice Address - Phone:952-933-8900
Practice Address - Fax:952-945-9536
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3557103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN920215300Medicaid
MN61-56740OtherMEDICA - UBH
MN996N6AJOtherBLUE CROSS/BS
MN996N6AJOtherBLUE CROSS/BS