Basic Information
| Provider Information | |||||||||
| NPI: | 1770699324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | JANA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPH, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788037600 | ||||||||
| FaxNumber: | 4788038596 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788037600 | ||||||||
| FaxNumber: | 4788038596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA9102896 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 006718 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00005751 | 01 | FL | FLORIDA PRESCRIBING QUALIFICATION | OTHER | 1721-023 | 01 | WI | WISCONSIN DEPT OF REGULATION AND LICENSING | OTHER | 9102896 | 01 | FL | FLORIDA DEPT OF HEALTH PHYSICIAN ASST LICENSURE | OTHER | MR2213320 | 01 | IA | DEA (IA CURRENT) | OTHER | 1060096 | 01 | NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS | OTHER | 6718 | 01 | GA | PHYSICIAN ASSISTANT | OTHER | MR1113682 | 01 | MN | DEA - (MN EXPIRED 04/30/2007) | OTHER | 292421800 | 05 | FL | MEDICAID | 9874 | 01 | MN | MINNESOTA BOARD OF MEDICAL PRACTICE PHYSICIAN ASST LICENSURE (EXP 06-30-2005) | OTHER | UNKNOWN | 01 | IA | MAGELLAN OF IOWA - BROADLAWNS MEDICAL CENTER | OTHER | 002087 | 01 | IA | IOWA DEPT OF PUBLIC HEALTH MEDICAL LICENSE | OTHER | 006718 | 01 | GA | GEORGIA COMPOSITE MEDICAL BOARD LICENSE | OTHER | 5101395 | 01 | IA | IOWA CONTROLLED SUBSTANCE ACT LICENSE (EXPIRED) | OTHER | U8969Z | 01 | FL | MEDICARE | OTHER |