Provider Demographics
NPI:1043917842
Name:GRAY, JACOB RYAN (DNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:GRAY
Suffix:
Gender:
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16891 HOLLINGS TRL NW
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-4513
Mailing Address - Country:US
Mailing Address - Phone:256-609-7502
Mailing Address - Fax:
Practice Address - Street 1:9238 MADISON BLVD STE 750
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9164
Practice Address - Country:US
Practice Address - Phone:256-724-8880
Practice Address - Fax:888-951-7515
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-184373363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health