Provider Demographics
NPI:1265714034
Name:GRAY, JERI LYNN (LMSW)
Entity type:Individual
Prefix:MS
First Name:JERI
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4987 STATE ROUTE 410
Mailing Address - Street 2:
Mailing Address - City:CASTORLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13620-2305
Mailing Address - Country:US
Mailing Address - Phone:315-681-0477
Mailing Address - Fax:
Practice Address - Street 1:21986 COLE RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9595
Practice Address - Country:US
Practice Address - Phone:315-493-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078271-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health