Provider Demographics
NPI:1346630126
Name:GRAHAM, JEMICEO (LCAS-A)
Entity Type:Individual
Prefix:
First Name:JEMICEO
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:JEMICEO
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS
Mailing Address - Street 1:3410 HEALY DR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1403
Mailing Address - Country:US
Mailing Address - Phone:336-768-7936
Mailing Address - Fax:
Practice Address - Street 1:2706 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3657
Practice Address - Country:US
Practice Address - Phone:336-272-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NCLCAS-A 21464101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator