Provider Demographics
NPI:1972123107
Name:GRAY, JESSICA LYNN I
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GRAY
Suffix:I
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 1:77 WALL ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-2000
Mailing Address - Country:US
Mailing Address - Phone:678-977-1703
Mailing Address - Fax:
Practice Address - Street 1:77 WALL ST
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-2000
Practice Address - Country:US
Practice Address - Phone:678-977-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0071181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical