Healthcare Provider Details

I. General information

NPI: 1598306888
Provider Name (Legal Business Name): JORDAN KRISTINE GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N 47TH ST
KANSAS CITY KS
66102-1705
US

IV. Provider business mailing address

4850 W 207TH ST
BUCYRUS KS
66013-8502
US

V. Phone/Fax

Practice location:
  • Phone: 913-287-0007
  • Fax:
Mailing address:
  • Phone: 913-710-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3516
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: