Healthcare Provider Details

I. General information

NPI: 1346357498
Provider Name (Legal Business Name): JENNIFER LETICIA GRAYSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 REYNOIR ST STE 202
BILOXI MS
39530-4109
US

IV. Provider business mailing address

POST OFFICE BOX 6579
D'IBERVILLE MS
39540
US

V. Phone/Fax

Practice location:
  • Phone: 228-594-8000
  • Fax: 228-594-8002
Mailing address:
  • Phone: 228-594-8000
  • Fax: 228-594-8002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17609
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: