Healthcare Provider Details

I. General information

NPI: 1174678395
Provider Name (Legal Business Name): JASON DE-LEON GRAY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5599 HIGHWAY 311
HOUMA LA
70360-2866
US

IV. Provider business mailing address

5599 HIGHWAY 311
HOUMA LA
70360-2866
US

V. Phone/Fax

Practice location:
  • Phone: 985-857-3615
  • Fax: 985-857-3765
Mailing address:
  • Phone: 985-857-3615
  • Fax: 985-857-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN120214
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: