MEDICARE: JESSICA 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	174400000X	Specialist	7501004769	MI

General Provider Information

NPI Number	:	1841665296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GRAY

Provider Business Mailing Address
First Line	:	509 CENTER AVE
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-5974
Country	:	US
Telephone Number	:	734-548-0007
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 CENTER AVE
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-5974
Country	:	US
Telephone Number	:	734-548-0007
Fax Number	:

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

Provider Enumeration Date	:	12/10/2015
Last Update Date	:	12/10/2015

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