MEDICARE: JASON GRAHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1264458	TX

General Provider Information

NPI Number	:	1336513167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON GRAHAM

Provider Business Mailing Address
First Line	:	10304 GRAYHAWK LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8543
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 WESTERN CENTER BLVD
Second Line	:	SUITE 312
City	:	FORT WORTH
State	:	TX
Zip	:	76131-4302
Country	:	US
Telephone Number	:	817-847-0200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2015
Last Update Date	:	11/17/2015

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