Provider Demographics
NPI:1376275099
Name:GRAHAM, JORDAN SKYE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:SKYE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7489 ROCKFISH RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6131
Mailing Address - Country:US
Mailing Address - Phone:910-584-6739
Mailing Address - Fax:833-260-0543
Practice Address - Street 1:7489 ROCKFISH RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-6131
Practice Address - Country:US
Practice Address - Phone:910-584-6739
Practice Address - Fax:833-260-0543
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0178491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical