Provider Demographics
NPI:1831406701
Name:GRAHAM, JASON ROBERT
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 E VICTORY AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76501-1711
Mailing Address - Country:US
Mailing Address - Phone:254-295-6076
Mailing Address - Fax:
Practice Address - Street 1:213 E VICTORY AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76501-1711
Practice Address - Country:US
Practice Address - Phone:254-295-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX476475247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist