Provider Demographics
NPI:1215699111
Name:GRAY, JASON SCOTT (RD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:GRAY
Suffix:
Gender:M
Credentials:RD
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 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 PINEVIEW DR STE 205
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3814
Practice Address - Country:US
Practice Address - Phone:336-329-3295
Practice Address - Fax:336-355-5204
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NCL005641133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered