Healthcare Provider Details

I. General information

NPI: 1821472382
Provider Name (Legal Business Name): JESSICA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 AUTO CLUB DR
DEARBORN MI
48126-2779
US

IV. Provider business mailing address

2280 E GRAND RIVER AVE
HOWELL MI
48843-8503
US

V. Phone/Fax

Practice location:
  • Phone: 313-425-4500
  • Fax:
Mailing address:
  • Phone: 517-546-4126
  • Fax: 517-546-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097974
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: