Provider Demographics
NPI:1336426030
Name:DIAL, JACK GRADY (PHD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:GRADY
Last Name:DIAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 WINGREN DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-2763
Mailing Address - Country:US
Mailing Address - Phone:972-541-0818
Mailing Address - Fax:
Practice Address - Street 1:4201 WINGREN DR
Practice Address - Street 2:SUITE 112
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-2763
Practice Address - Country:US
Practice Address - Phone:972-541-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22641103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical