Provider Demographics
NPI:1467511295
Name:GRIMES, JACK SILER JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:SILER
Last Name:GRIMES
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9016 RIVER CRES
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23433-1304
Mailing Address - Country:US
Mailing Address - Phone:757-238-2038
Mailing Address - Fax:757-238-2038
Practice Address - Street 1:15 DAVIS ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23702-3021
Practice Address - Country:US
Practice Address - Phone:757-238-2038
Practice Address - Fax:757-238-2038
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040003861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical