Healthcare Provider Details

I. General information

NPI: 1740119486
Provider Name (Legal Business Name): JACKSON GRAY HERZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E 60TH ST
NEW YORK NY
10022-1939
US

IV. Provider business mailing address

113 E 60TH ST
NEW YORK NY
10022-1939
US

V. Phone/Fax

Practice location:
  • Phone: 917-675-2134
  • Fax:
Mailing address:
  • Phone: 917-675-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number40768
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127734
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: