Provider Demographics
NPI:1689920175
Name:GRAFFAGNINO, JORDAN BRETT (LSA, CSFA)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:BRETT
Last Name:GRAFFAGNINO
Suffix:
Gender:M
Credentials:LSA, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9325 PHELAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-5122
Mailing Address - Country:US
Mailing Address - Phone:409-554-1138
Mailing Address - Fax:
Practice Address - Street 1:9325 PHELAN BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5122
Practice Address - Country:US
Practice Address - Phone:409-554-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00483208600000X, 246ZC0007X
TX136982246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist