Provider Demographics
NPI:1912411919
Name:GRANTHAM, JADE WHITNEY
Entity Type:Individual
Prefix:MRS
First Name:JADE
Middle Name:WHITNEY
Last Name:GRANTHAM
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 1:2500 BOBCAT VILLAGE CENTER RD UNIT H
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-8476
Mailing Address - Country:US
Mailing Address - Phone:800-217-9289
Mailing Address - Fax:
Practice Address - Street 1:2500 BOBCAT VILLAGE CENTER RD UNIT H
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-8476
Practice Address - Country:US
Practice Address - Phone:239-778-6574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-41509103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty