Provider Demographics
NPI:1124395256
Name:GRADDICK, JENNIFER HOLLY (LISW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HOLLY
Last Name:GRADDICK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 N LINN ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-2147
Mailing Address - Country:US
Mailing Address - Phone:319-541-7975
Mailing Address - Fax:
Practice Address - Street 1:123 N LINN ST STE 2D
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2147
Practice Address - Country:US
Practice Address - Phone:319-541-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0075341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA600760369Medicaid