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General NPI Number Information
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NPI Number | 1972885440
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Entity Type | Individual
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Provider Name | JACLYN GRAD PH.D.
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Gender | Female
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Dates
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Enumeration Date | 09/12/2011
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Last Update Date | 02/19/2014
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Provider Practice Location Address
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Address Line | 3851 ROGER BROOKE DR MCHEQD
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234-4501
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Country | US
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Telephone | 210-916-2460
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 280148
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City | JACKSONVILLE
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State | FL
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Zip | 32228-0148
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Country | US
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Telephone | 904-270-4338
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 001304
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License Number State | IA
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