Provider Demographics
NPI:1487300802
Name:GRAHAM, JESSICA MONIQUE (OTA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MONIQUE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 BELMONT PL
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-7839
Mailing Address - Country:US
Mailing Address - Phone:850-284-8644
Mailing Address - Fax:
Practice Address - Street 1:15127 S JOG RD STE 210
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-1251
Practice Address - Country:US
Practice Address - Phone:561-498-1098
Practice Address - Fax:561-495-2524
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14759225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist