Healthcare Provider Details

I. General information

NPI: 1235414350
Provider Name (Legal Business Name): JORDAN ROBERT GRAY PRO. COUNSELOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S UNIVERSITY AVE STE 1500
PROVO UT
84601-4427
US

IV. Provider business mailing address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-7112
  • Fax:
Mailing address:
  • Phone: 801-373-4760
  • Fax: 801-373-0639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7903342-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7903342-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: