Provider Demographics
NPI:1942893136
Name:GRAHAM, JENNIFER MARIE (MS, RDN, CSP, LD/N)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS, RDN, CSP, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7789 DEER POND LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-9023
Mailing Address - Country:US
Mailing Address - Phone:904-710-8714
Mailing Address - Fax:
Practice Address - Street 1:348 ENTERPRISE DR STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5697
Practice Address - Country:US
Practice Address - Phone:904-710-8714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7159133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric