MEDICARE: JESSINA GRAHAM APRN, C-NP

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	363LF0000X	Family Nurse Practitioner	100661	OK
2	363L00000X	Nurse Practitioner	14613-33	WI
3	163W00000X	Registered Nurse	100661	OK

General Provider Information

NPI Number	:	1861801565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSINA GRAHAM APRN, C-NP

Provider Business Mailing Address
First Line	:	2921 LANDMARK PL SUITE 215
Second Line	:	#418
City	:	MADISON
State	:	WI
Zip	:	53713-1825
Country	:	US
Telephone Number	:	405-824-1705
Fax Number	:	405-307-6660

Provider Business Practice Location Address
First Line	:	2921 LANDMARK PL STE 215
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53713-4248
Country	:	US
Telephone Number	:	405-824-1705
Fax Number	:	608-299-3707

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

Provider Enumeration Date	:	08/06/2014
Last Update Date	:	11/30/2024

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