Provider Demographics
NPI:1124668421
Name:GRAHAM, JEANNINE
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10205 LILY GREEN CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6665
Mailing Address - Country:US
Mailing Address - Phone:240-441-5851
Mailing Address - Fax:
Practice Address - Street 1:10205 LILY GREEN CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-6665
Practice Address - Country:US
Practice Address - Phone:240-441-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNO OTHER PROVIDER IDENTIFIERS AT THIS TIME