Healthcare Provider Details

I. General information

NPI: 1225907389
Provider Name (Legal Business Name): JACQUELINE GRAY MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ZORN AVE
LOUISVILLE KY
40206-1433
US

IV. Provider business mailing address

3058 BARDSTOWN RD # 1039
LOUISVILLE KY
40205-3020
US

V. Phone/Fax

Practice location:
  • Phone: 706-551-3656
  • Fax:
Mailing address:
  • Phone: 706-551-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number13805
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: