Healthcare Provider Details

I. General information

NPI: 1407779143
Provider Name (Legal Business Name): JAHDASHIA GRAHAM
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 US HIGHWAY 9W
HIGHLAND NY
12528-1025
US

IV. Provider business mailing address

3501 US HIGHWAY 9W
HIGHLAND NY
12528-1025
US

V. Phone/Fax

Practice location:
  • Phone: 845-873-7918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number356520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: