Healthcare Provider Details

I. General information

NPI: 1609750652
Provider Name (Legal Business Name): DOUGLAS WRAY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2476 E NORTHSIDE DR
JACKSON MS
39211-4924
US

V. Phone/Fax

Practice location:
  • Phone: 662-312-3569
  • Fax:
Mailing address:
  • Phone: 662-312-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number910154
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: