Provider Demographics
NPI:1407858962
Name:GRIMM, JESSICA JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:JEAN
Last Name:GRIMM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 E LOOP 1604 N
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3179
Mailing Address - Country:US
Mailing Address - Phone:210-659-4111
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:
Practice Address - City:RANDOLPH A F B
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-5526
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6743T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist