Provider Demographics
NPI:1871935205
Name:GRAYBURN, JESSICA ANN (MA, AT, IMH 11373)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ANN
Last Name:GRAYBURN
Suffix:
Gender:F
Credentials:MA, AT, IMH 11373
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 UMATILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-8418
Mailing Address - Country:US
Mailing Address - Phone:352-669-8000
Mailing Address - Fax:
Practice Address - Street 1:633 UMATILLA BLVD
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8418
Practice Address - Country:US
Practice Address - Phone:352-669-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 11373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health