Basic Information
| Provider Information | |||||||||
| NPI: | 1326405234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29D STONEHILL RD | ||||||||
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| City: | OSWEGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605439449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157910549 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 ESSINGTON RD | ||||||||
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| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604354912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157292160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2016 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 056011345 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.