Basic Information
| Provider Information | |||||||||
| NPI: | 1306995386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10419 INTRIGUE ST | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773565760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1020 RIVERWOOD CT | ||||||||
| Address2: | BUILDING #3 | ||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773042811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 18371 | TX | Y | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 8643 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.