Provider Demographics
NPI:1801989868
Name:GRAHAM, JESSICA
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4019 W 12600 S
Mailing Address - Street 2:#110
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096
Mailing Address - Country:US
Mailing Address - Phone:801-302-9482
Mailing Address - Fax:801-302-5532
Practice Address - Street 1:4019 W 12600 SOUTH
Practice Address - Street 2:SUITE #110
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096
Practice Address - Country:US
Practice Address - Phone:801-302-9482
Practice Address - Fax:801-302-5532
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5267304-9934152W00000X
UT5267304-8904152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT84414OtherPEHP
UT868724OtherDESERET MUTUAL BENEFIT AD
UT52673049901001OtherBCBS ID #
UTH870369 0819OtherGROUP & PENSION ADM.
UTH870369 0819OtherGROUP & PENSION ADM.