Provider Demographics
NPI:1669948543
Name:GRAY, JACQUELINE REBECCA (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:REBECCA
Last Name:GRAY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1818
Mailing Address - Country:US
Mailing Address - Phone:206-477-6093
Mailing Address - Fax:
Practice Address - Street 1:13030 121ST WAY NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3008
Practice Address - Country:US
Practice Address - Phone:206-477-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60502206163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse