Provider Demographics
NPI:1437808508
Name:GRELLMANN, JASON DAVID
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:DAVID
Last Name:GRELLMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 BOREN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6517
Mailing Address - Country:US
Mailing Address - Phone:269-845-5957
Mailing Address - Fax:
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program