Provider Demographics
NPI:1497036099
Name:GRAHAM, JACKLYNN REYNA (RN)
Entity Type:Individual
Prefix:
First Name:JACKLYNN
Middle Name:REYNA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 45013 BOX 3193
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96338
Mailing Address - Country:US
Mailing Address - Phone:305-424-6089
Mailing Address - Fax:
Practice Address - Street 1:MEDDAC-JAPAN
Practice Address - Street 2:UNIT 45011
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96343-5011
Practice Address - Country:US
Practice Address - Phone:315-263-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS115334163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse