Provider Demographics
NPI:1326487216
Name:GRAHAM, JENNIFER T (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 2ND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-2757
Mailing Address - Country:US
Mailing Address - Phone:631-560-2694
Mailing Address - Fax:
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-312-5579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2018-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY016621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant