Basic Information
| Provider Information | |||||||||
| NPI: | 1902399546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | LUREYE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 E DESHLER AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432062925 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432071708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144458131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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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 | 163W00000X | RN-349216 | OH | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN-157559 | AZ | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN-95046100 | CA | N | Nursing Service Providers | Registered Nurse | 163WA0400X | RN-95046100 | CA | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WA0400X | RN-157559 | AZ | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WG0000X | RN-349216 | OH | N | Nursing Service Providers | Registered Nurse | General Practice | 163WG0000X | RN-157559 | AZ | N | Nursing Service Providers | Registered Nurse | General Practice | 163WG0000X | RN-95046100 | CA | N | Nursing Service Providers | Registered Nurse | General Practice | 163WA0400X | RN-349216 | OH | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.