Provider Demographics
NPI:1457844656
Name:GRAHAM, JEAN ANN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
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:PO BOX 340744
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-0013
Mailing Address - Country:US
Mailing Address - Phone:512-299-1500
Mailing Address - Fax:
Practice Address - Street 1:2503 SARATOGA DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78733-1240
Practice Address - Country:US
Practice Address - Phone:512-299-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 374U00000X
TX219551835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No172V00000XOther Service ProvidersCommunity Health Worker
No374U00000XNursing Service Related ProvidersHome Health Aide