Provider Demographics
NPI:1689402794
Name:GRAY, JACINDA
Entity type:Individual
Prefix:
First Name:JACINDA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SPARKS CIR
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:AR
Mailing Address - Zip Code:72611-3015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 SPARKS CIR
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:AR
Practice Address - Zip Code:72611-3015
Practice Address - Country:US
Practice Address - Phone:870-350-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered