Provider Demographics
NPI:1699144683
Name:GRAVES, JERRA
Entity type:Individual
Prefix:
First Name:JERRA
Middle Name:
Last Name:GRAVES
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:PO BOX 32951
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79120-2951
Mailing Address - Country:US
Mailing Address - Phone:067-185-3998
Mailing Address - Fax:
Practice Address - Street 1:2207 S WESTERN ST STE 110
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1572
Practice Address - Country:US
Practice Address - Phone:067-185-3998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-19
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NM4661225100000X
TX1311406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist