Healthcare Provider Details

I. General information

NPI: 1609693803
Provider Name (Legal Business Name): JACOB GRAVES CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

5003 SOUTHWOOD DR
GODFREY IL
62035-1338
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone: 618-570-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: