Provider Demographics
NPI:1548329568
Name:GRAHAM, JERRY ALAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALAN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 CENTURY BLVD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3398
Mailing Address - Country:US
Mailing Address - Phone:404-325-8900
Mailing Address - Fax:404-325-8900
Practice Address - Street 1:1778 CENTURY BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3398
Practice Address - Country:US
Practice Address - Phone:404-325-8900
Practice Address - Fax:404-325-8900
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001933103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52486388OtherBLUE CROSS BLUE SHILED
GA62TCCNFMedicare ID - Type UnspecifiedPROVIDER ID #