Provider Demographics
NPI:1477231074
Name:GRAHAM, JENNESSEE ELIZABETH
Entity Type:Individual
Prefix:
First Name:JENNESSEE
Middle Name:ELIZABETH
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 1:469 BRYSON CIR
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-1286
Mailing Address - Country:US
Mailing Address - Phone:229-300-0776
Mailing Address - Fax:
Practice Address - Street 1:469 BRYSON CIR
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-1286
Practice Address - Country:US
Practice Address - Phone:229-300-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18830224Z00000X
GAOTA002865224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant