Provider Demographics
NPI:1497582118
Name:GRAHAM, JACQUELINE JARVIS
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JARVIS
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 1:801A E GENERAL STEWART WAY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2661
Mailing Address - Country:US
Mailing Address - Phone:912-255-6009
Mailing Address - Fax:
Practice Address - Street 1:801A E GENERAL STEWART WAY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2661
Practice Address - Country:US
Practice Address - Phone:912-255-6009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035166183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH035166OtherPRH