MEDICARE: MRS. JADE WHITNEY GRANTHAM

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	103K00000X	Behavior Analyst	1-20-41509	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912411919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JADE WHITNEY GRANTHAM

Provider Business Mailing Address
First Line	:	2500 BOBCAT VILLAGE CENTER RD UNIT H
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34288-8476
Country	:	US
Telephone Number	:	800-217-9289
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 BOBCAT VILLAGE CENTER RD UNIT H
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34288-8476
Country	:	US
Telephone Number	:	239-778-6574
Fax Number	:

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

Provider Enumeration Date	:	11/29/2017
Last Update Date	:	01/18/2024

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