Provider Demographics
NPI:1073219812
Name:GRIFFIN, JENNIFER NICOLE (LADA II)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:LADA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4385 WANATAH ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-5260
Mailing Address - Country:US
Mailing Address - Phone:901-846-8899
Mailing Address - Fax:
Practice Address - Street 1:530 OAK COURT DR STE 270
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-3724
Practice Address - Country:US
Practice Address - Phone:901-846-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000001370101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)