Basic Information
| Provider Information | |||||||||
| NPI: | 1396763249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVEN | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8007 LYNDON CIRCLE WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026908024 | ||||||||
| FaxNumber: | 5026908090 | ||||||||
| Practice Location | |||||||||
| Address1: | 8007 LYNDON CIRCLE WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026908024 | ||||||||
| FaxNumber: | 5026908090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 129389 | KY | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.