Provider Demographics
NPI:1467099150
Name:GRAHAM, JAYNE ANN (AFC PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:JAYNE
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:AFC PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 ROSE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307
Mailing Address - Country:US
Mailing Address - Phone:231-796-4512
Mailing Address - Fax:
Practice Address - Street 1:831 ROSE AVENUE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-796-4512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF540281082311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1098248Medicaid