Basic Information
Provider Information | |||||||||
NPI: | 1699122259 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAVES (BLEES) | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LAUREN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., CF-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 724 BROOKHILL RANCH RD APT C | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719099340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5015450110 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2600 COMPASS RD | ||||||||
Address2: |   | ||||||||
City: | GLENVIEW | ||||||||
State: | IL | ||||||||
PostalCode: | 60026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8777873430 | ||||||||
FaxNumber: | 8474410734 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2016 | ||||||||
LastUpdateDate: | 08/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 235Z00000X |   | AR | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.