Basic Information
| Provider Information | |||||||||
| NPI: | 1629270004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 KAEN ROAD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037425300 | ||||||||
| FaxNumber: | 5037425977 | ||||||||
| Practice Location | |||||||||
| Address1: | 38872 PROCTOR BLVD | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970558035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037226950 | ||||||||
| FaxNumber: | 5037226939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 05/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 372600000X | N | Nursing Service Related Providers | Adult Companion | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.