Healthcare Provider Details

I. General information

NPI: 1104432491
Provider Name (Legal Business Name): JENNIFER LEE GRAHAM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11945 FANCY GAP HWY
CANA VA
24317-3401
US

IV. Provider business mailing address

PO BOX 9
LAUREL FORK VA
24352-0009
US

V. Phone/Fax

Practice location:
  • Phone: 276-755-2203
  • Fax: 276-398-3331
Mailing address:
  • Phone: 276-398-2292
  • Fax: 276-398-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701009936
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: