Provider Demographics
NPI:1366567570
Name:GRAHAM, JENNIFER L (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 ASBURY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-1811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 ASBURY ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAMILTON
Practice Address - State:MA
Practice Address - Zip Code:01982-1811
Practice Address - Country:US
Practice Address - Phone:617-970-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist