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General NPI Number Information
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NPI Number | 1346630126
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Entity Type | Individual
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Provider Name | JEMICEO GRAHAM LCAS-A
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Gender | Female
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Dates
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Enumeration Date | 01/30/2015
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Last Update Date | 07/19/2019
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Provider Practice Location Address
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Address Line | 2706 N CHURCH ST
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City | GREENSBORO
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State | NC
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Zip | 27405-3657
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Country | US
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Telephone | 336-272-9990
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Fax |
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Provider Business Mailing Address
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Address Line | 3410 HEALY DR SUITE 117
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City | WINSTON SALEM
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State | NC
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Zip | 27103-1403
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Country | US
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Telephone | 336-768-7936
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Fax |
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCAS-A 21464
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License Number State | NC
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