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General NPI Number Information
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NPI Number | 1205791035
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Entity Type | Individual
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Provider Name | JENNELLE RENE GRAVES SUDCC
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Gender | Female
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Dates
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Enumeration Date | 12/23/2025
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Last Update Date | 12/23/2025
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Provider Practice Location Address
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Address Line | 10087 TERRA LOMA DR
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City | RANCHO CORDOVA
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State | CA
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Zip | 95670-3202
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Country | US
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Telephone | 916-848-2671
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Fax |
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Provider Business Mailing Address
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Address Line | 940 VINTAGE OAK AVE
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City | GALT
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State | CA
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Zip | 95632-3020
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Country | US
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Telephone | 209-765-7871
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Fax | 209-765-7871
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 20122
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License Number State | CA
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