Healthcare Provider Details

I. General information

NPI: 1093621617
Provider Name (Legal Business Name): JENNIFER LEIANNE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 RIDGEWOOD AVE STE 6
HOLLY HILL FL
32117-3647
US

IV. Provider business mailing address

40 RIVER RIDGE TRL
ORMOND BEACH FL
32174-4315
US

V. Phone/Fax

Practice location:
  • Phone: 405-543-9692
  • Fax:
Mailing address:
  • Phone: 405-543-9692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH26667
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: