Healthcare Provider Details

I. General information

NPI: 1508647660
Provider Name (Legal Business Name): JORDON GRABAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 STATE STREET
WATERTOWN NY
13601
US

IV. Provider business mailing address

650 STATE STREET
WATERTOWN NY
13601-1251
US

V. Phone/Fax

Practice location:
  • Phone: 315-755-1251
  • Fax:
Mailing address:
  • Phone: 315-755-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number774422
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number774422
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number774422
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: