MEDICARE: JACKIE 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	235Z00000X	Speech-Language Pathologist		WI

General Provider Information

NPI Number	:	1659204709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE GRAY

Provider Business Mailing Address
First Line	:	N88W16801 MAIN ST
Second Line	:
City	:	MENOMONEE FALLS
State	:	WI
Zip	:	53051-2973
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	N88W16801 MAIN ST
Second Line	:
City	:	MENOMONEE FALLS
State	:	WI
Zip	:	53051-2973
Country	:	US
Telephone Number	:	262-255-7125
Fax Number	:

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

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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Directions to “ JACKIE GRAY ” Practice Location

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