Healthcare Provider Details

I. General information

NPI: 1396307674
Provider Name (Legal Business Name): JESSICA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W EVANS ST STE 102
FLORENCE SC
29501-3388
US

IV. Provider business mailing address

1001 W EVANS ST STE 102
FLORENCE SC
29501-3388
US

V. Phone/Fax

Practice location:
  • Phone: 843-253-0435
  • Fax:
Mailing address:
  • Phone: 843-253-0435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHTP1068
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: