Healthcare Provider Details

I. General information

NPI: 1508167560
Provider Name (Legal Business Name): JENNIFER ANNE GRAY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 04/22/2023
Certification Date: 04/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W THOMAS RD # 400
PHOENIX AZ
85013-4407
US

IV. Provider business mailing address

240 W THOMAS RD # 400
PHOENIX AZ
85013-4407
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-6262
  • Fax: 602-406-6261
Mailing address:
  • Phone: 602-406-6262
  • Fax: 602-406-6261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4139
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4139
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: