MEDICARE: MRS. JAE LYNN GRAHAM PA-C, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA01039	TX

General Provider Information

NPI Number	:	1417093253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAE LYNN GRAHAM PA-C, MS

Provider Business Mailing Address
First Line	:	1200 BINZ ST STE 400
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6942
Country	:	US
Telephone Number	:	713-520-6016
Fax Number	:	713-893-1342

Provider Business Practice Location Address
First Line	:	1200 BINZ ST STE 400
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6942
Country	:	US
Telephone Number	:	713-520-6016
Fax Number	:	713-893-1342

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	10/11/2023

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