Provider Demographics
NPI:1730508094
Name:GRAY, JENNY (MA, LPC)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:SHEEGOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4686 BRISTOL TRACE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4686 BRISTOL TRACE TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6947
Practice Address - Country:US
Practice Address - Phone:817-301-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66229101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional