Provider Demographics
NPI:1316916059
Name:GRAHAM, JACQUELINE RENEE (CSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S 400 E
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2135
Mailing Address - Country:US
Mailing Address - Phone:801-326-7444
Mailing Address - Fax:801-783-5559
Practice Address - Street 1:124 S 400 E
Practice Address - Street 2:SUITE 450
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2135
Practice Address - Country:US
Practice Address - Phone:801-326-7444
Practice Address - Fax:801-783-5559
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2089903502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health