Provider Demographics
NPI:1407120066
Name:GRAVES, JESSICA LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAURA
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LAURA
Other - Last Name:BRENNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:333 S 38TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4937
Mailing Address - Country:US
Mailing Address - Phone:918-840-5276
Mailing Address - Fax:918-877-1312
Practice Address - Street 1:333 S 38TH ST STE E
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4937
Practice Address - Country:US
Practice Address - Phone:918-840-5276
Practice Address - Fax:918-877-1312
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-770363A00000X
OKPA2129363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant