Provider Demographics
NPI:1235492778
Name:GRAHAM, JENNIFER TAYLOR (ANP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TAYLOR
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122309 DEPT 2309
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 350
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0404
Practice Address - Country:US
Practice Address - Phone:337-494-2750
Practice Address - Fax:337-494-2760
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06581363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP06581OtherSTATE LICENSE
LA2530984Medicaid