Provider Demographics
NPI:1093391369
Name:GRAHAM, JESSICA COLETTE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:COLETTE
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 1:829 N LOOP 340 # A
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2592
Mailing Address - Country:US
Mailing Address - Phone:254-202-3700
Mailing Address - Fax:
Practice Address - Street 1:829 N LOOP 340 STE A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-2592
Practice Address - Country:US
Practice Address - Phone:254-202-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203542183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician