Provider Demographics
NPI:1043612575
Name:GRILLO, JACOB ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ADAM
Last Name:GRILLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19916 OLD OWEN RD # 510
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9778
Mailing Address - Country:US
Mailing Address - Phone:360-453-7715
Mailing Address - Fax:
Practice Address - Street 1:909 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2031
Practice Address - Country:US
Practice Address - Phone:360-453-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant