=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326487216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER T GRAHAM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2013
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 WILLIAM ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-312-5579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 2ND ST APT 2
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07302-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-560-2694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 016621
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 25MP00383400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------