MEDICARE: JASMINE C GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639788698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE C GRAY

Provider Business Mailing Address
First Line	:	1300 N VEL R PHILLIPS AVE APT 301
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-4008
Country	:	US
Telephone Number	:	141-455-1547
Fax Number	:	414-551-5416

Provider Business Practice Location Address
First Line	:	1300 N VEL R PHILLIPS AVE APT 301
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-4008
Country	:	US
Telephone Number	:	141-455-1541
Fax Number	:	414-551-5416

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2020
Last Update Date	:	07/27/2020

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Directions to “ JASMINE C GRAY ” Practice Location

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