Healthcare Provider Details

I. General information

NPI: 1205791035
Provider Name (Legal Business Name): JENNELLE RENE GRAVES SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10087 TERRA LOMA DR
RANCHO CORDOVA CA
95670-3202
US

IV. Provider business mailing address

940 VINTAGE OAK AVE
GALT CA
95632-3020
US

V. Phone/Fax

Practice location:
  • Phone: 916-848-2671
  • Fax:
Mailing address:
  • Phone: 209-765-7871
  • Fax: 209-765-7871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: