Provider Demographics
NPI:1396763249
Name:GRAVEN, JACQUELYN J (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:J
Last Name:GRAVEN
Suffix:
Gender:F
Credentials:PSYD
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Other - Credentials:
Mailing Address - Street 1:8007 LYNDON CIRCLE WAY
Mailing Address - Street 2:STE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222
Mailing Address - Country:US
Mailing Address - Phone:502-690-8024
Mailing Address - Fax:502-690-8090
Practice Address - Street 1:8007 LYNDON CIRCLE WAY
Practice Address - Street 2:STE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-690-8024
Practice Address - Fax:502-690-8090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY129389103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000962478OtherBCBS KY
KYK184131Medicare PIN