Basic Information
| Provider Information | |||||||||
| NPI: | 1861801565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JESSINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053075720 | ||||||||
| FaxNumber: | 4053076660 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 HEALTHPLEX PKWY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730729738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053075720 | ||||||||
| FaxNumber: | 4053075721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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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 | 163W00000X | 100661 | OK | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 100661 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.