Provider Demographics
NPI:1598306888
Name:GRAVES, JORDAN KRISTINE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KRISTINE
Last Name:GRAVES
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 1:4850 W 207TH ST
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:KS
Mailing Address - Zip Code:66013-8502
Mailing Address - Country:US
Mailing Address - Phone:913-710-8006
Mailing Address - Fax:
Practice Address - Street 1:1301 N 47TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1705
Practice Address - Country:US
Practice Address - Phone:913-287-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3516101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional