Provider Demographics
NPI:1801946280
Name:GRAHAM, JERI C (LCSW)
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:C
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 SE CASS AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4954
Mailing Address - Country:US
Mailing Address - Phone:541-673-8404
Mailing Address - Fax:541-673-1042
Practice Address - Street 1:727 SE CASS AVE STE 306
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-4954
Practice Address - Country:US
Practice Address - Phone:541-673-8404
Practice Address - Fax:541-673-1042
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000TLCPPMedicare PIN