Provider Demographics
NPI:1902371412
Name:GRAHAM, JESSICA KAY (LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAY
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-1563
Mailing Address - Country:US
Mailing Address - Phone:218-625-2685
Mailing Address - Fax:
Practice Address - Street 1:4000 W 9TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-1563
Practice Address - Country:US
Practice Address - Phone:218-625-2675
Practice Address - Fax:218-625-2698
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical