Provider Demographics
NPI:1427548288
Name:WISE-GRAHAM, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:WISE-GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3505 CAMINO DEL RIO S STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4016
Mailing Address - Country:US
Mailing Address - Phone:888-616-0864
Mailing Address - Fax:
Practice Address - Street 1:3505 CAMINO DEL RIO S STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4016
Practice Address - Country:US
Practice Address - Phone:888-616-0864
Practice Address - Fax:888-616-0864
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician