Provider Demographics
NPI:1083375398
Name:GRIFFIN, JESSICA TIFFANY
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TIFFANY
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7139 LAVERNE LN APT 1W
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4972
Mailing Address - Country:US
Mailing Address - Phone:708-321-0160
Mailing Address - Fax:
Practice Address - Street 1:19000 HALSTED ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-4204
Practice Address - Country:US
Practice Address - Phone:708-957-7152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009145225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty