Provider Demographics
NPI:1366729196
Name:GRAY, JASPER EARL JR
Entity type:Individual
Prefix:MR
First Name:JASPER
Middle Name:EARL
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 WECO ST
Mailing Address - Street 2:
Mailing Address - City:WHISTLER
Mailing Address - State:AL
Mailing Address - Zip Code:36612
Mailing Address - Country:US
Mailing Address - Phone:251-458-9440
Mailing Address - Fax:
Practice Address - Street 1:3727 WECO ST
Practice Address - Street 2:
Practice Address - City:WHISTLER
Practice Address - State:AL
Practice Address - Zip Code:36612-1155
Practice Address - Country:US
Practice Address - Phone:251-458-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman