Provider Demographics
NPI:1447713920
Name:GRAHAM, JACK GREGORY (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:GREGORY
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28792-2841
Mailing Address - Country:US
Mailing Address - Phone:610-703-7396
Mailing Address - Fax:610-703-7396
Practice Address - Street 1:212 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-2841
Practice Address - Country:US
Practice Address - Phone:610-703-7396
Practice Address - Fax:610-703-7396
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2025-01997207XS0106X, 207X00000X
IN01092322A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2025-01997OtherSTATE MEDICAL LICENSE
IN01092322AOtherSTATE LICENSE
IN300085092Medicaid