Healthcare Provider Details

I. General information

NPI: 1124124045
Provider Name (Legal Business Name): JILL MAVEN GRAY PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL MARIE ADAMS LP

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-4728
US

IV. Provider business mailing address

4201 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-4728
US

V. Phone/Fax

Practice location:
  • Phone: 952-933-8900
  • Fax: 952-945-9536
Mailing address:
  • Phone: 952-933-8900
  • Fax: 952-945-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3557
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: