Provider Demographics
NPI:1144517715
Name:GRAHAM, JACOB MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MARTIN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0607
Mailing Address - Country:US
Mailing Address - Phone:601-518-7054
Mailing Address - Fax:
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23826207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALMD.33105OtherMEDICAL LICENSURE COMMISSION OF ALABAMA
MS23826OtherMEDICAL LICENSURE
ALMD.33105OtherMEDICAL LICENSURE COMMISSION OF ALABAMA