Healthcare Provider Details

I. General information

NPI: 1033901483
Provider Name (Legal Business Name): JACOB GRAVES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8385 DIVISION RD
WHITE CITY OR
97503-1176
US

IV. Provider business mailing address

1221 DISK DR
MEDFORD OR
97501-6638
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-5853
  • Fax: 541-826-5843
Mailing address:
  • Phone: 458-658-5930
  • Fax: 541-414-1123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: