Provider Demographics
NPI:1013574433
Name:GRIFFIN, JACKLYN CHANELL (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JACKLYN
Middle Name:CHANELL
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 W FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8301
Mailing Address - Country:US
Mailing Address - Phone:816-318-8022
Mailing Address - Fax:
Practice Address - Street 1:1215 W FOXWOOD DR
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-8301
Practice Address - Country:US
Practice Address - Phone:816-318-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010027555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily