Provider Demographics
NPI:1497398804
Name:GRAHAM, JONATHAN I (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:I
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6454 ALAMO AVE APT 1W
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3155
Mailing Address - Country:US
Mailing Address - Phone:501-247-7240
Mailing Address - Fax:
Practice Address - Street 1:6454 ALAMO AVE APT 1W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3155
Practice Address - Country:US
Practice Address - Phone:501-247-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty