Healthcare Provider Details

I. General information

NPI: 1235045303
Provider Name (Legal Business Name): JESSICA R GRAY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11828 CANON BLVD STE A
NEWPORT NEWS VA
23606-2554
US

IV. Provider business mailing address

110 COLISEUM XING # 5043
HAMPTON VA
23666-5971
US

V. Phone/Fax

Practice location:
  • Phone: 804-295-8510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024198443
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: