Provider Demographics
NPI:1255417259
Name:GRAHAM, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 MIDLAND TRL
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24426-5308
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:1ARH LANE
Practice Address - Street 2:
Practice Address - City:LOW MOOR
Practice Address - State:VA
Practice Address - Zip Code:24457
Practice Address - Country:US
Practice Address - Phone:540-862-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA05135246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist