Healthcare Provider Details

I. General information

NPI: 1891377065
Provider Name (Legal Business Name): JADE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W PEACHTREE ST NW STE 2300
ATLANTA GA
30309-3453
US

IV. Provider business mailing address

17279 SW JOHNSON ST
BEAVERTON OR
97003-5002
US

V. Phone/Fax

Practice location:
  • Phone: 503-481-5253
  • Fax:
Mailing address:
  • Phone: 503-481-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: