Provider Demographics
NPI:1861191330
Name:GRAHAM, JACOB JOSEPH GORDON
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOSEPH GORDON
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SIERRA MADRE VILLA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2040
Mailing Address - Country:US
Mailing Address - Phone:714-493-2742
Mailing Address - Fax:626-351-9493
Practice Address - Street 1:650 SIERRA MADRE VILLA AVE STE 110
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-2040
Practice Address - Country:US
Practice Address - Phone:626-351-9616
Practice Address - Fax:626-351-9493
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA135841106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist