Provider Demographics
NPI:1346811338
Name:LADNER-GRAHAM, JENNIFER MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:LADNER-GRAHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:LADNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1839 COOPER RD STE D
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2836
Mailing Address - Country:US
Mailing Address - Phone:601-749-9477
Mailing Address - Fax:601-288-4770
Practice Address - Street 1:1 LINCOLN PKWY STE 204
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3261
Practice Address - Country:US
Practice Address - Phone:601-288-4851
Practice Address - Fax:601-288-4770
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS611084103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103T00000XBehavioral Health & Social Service ProvidersPsychologist