Provider Demographics
NPI:1376692061
Name:GRISHAM, JACK HOLLAND (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HOLLAND
Last Name:GRISHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CHERRY ST NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7206
Mailing Address - Country:US
Mailing Address - Phone:770-427-2911
Mailing Address - Fax:770-422-2302
Practice Address - Street 1:122 CHERRY ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7206
Practice Address - Country:US
Practice Address - Phone:770-427-2911
Practice Address - Fax:770-422-2302
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000669103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist