Basic Information
| Provider Information | |||||||||
| NPI: | 1346630126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JEMICEO | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCAS-A | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GRAHAM | ||||||||
| OtherFirstName: | JEMICEO | ||||||||
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| OtherCredential: | LCAS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3410 HEALY DR | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367687936 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2706 N CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274053657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362729990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2015 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | LCAS-A 21464 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.