Provider Demographics
NPI:1407370356
Name:GRIM, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GRIM
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 1:2605 WILLOW STREET PIKE N
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584-9510
Mailing Address - Country:US
Mailing Address - Phone:717-464-2838
Mailing Address - Fax:717-464-3812
Practice Address - Street 1:2605 WILLOW STREET PIKE N
Practice Address - Street 2:
Practice Address - City:WILLOW STREET
Practice Address - State:PA
Practice Address - Zip Code:17584-9510
Practice Address - Country:US
Practice Address - Phone:717-464-2838
Practice Address - Fax:717-464-3812
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily