=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700672177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE BROWN GRAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2025
-----------------------------------------------------
Last Update Date | 01/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 BANDOL ST
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-600-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 BANDOL ST
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN04839
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN11037961
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------