Provider Demographics
NPI:1801101464
Name:GRAHAM, JENNIFER BLADES (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BLADES
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:BLADES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR
Mailing Address - Street 2:GENETICS CLINIC F3.43
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-2537
Mailing Address - Fax:214-456-2567
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:GENETICS CLINIC F3.43
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-2537
Practice Address - Fax:214-456-2567
Is Sole Proprietor?:No
Enumeration Date:2010-08-07
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
CO50314208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program