Provider Demographics
NPI:1831532092
Name:GRAHAM, JESSICA LYNN (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1401 SW PARKRIDGE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9200
Mailing Address - Country:US
Mailing Address - Phone:580-730-8015
Mailing Address - Fax:
Practice Address - Street 1:1401 SW PARKRIDGE BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9200
Practice Address - Country:US
Practice Address - Phone:580-730-8015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1105715225100000X
TN9689225100000X
OK5263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist