Provider Demographics
NPI:1477101731
Name:GRUNDY, JACQUELINE D
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:D
Last Name:GRUNDY
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 1:57731 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048-2627
Mailing Address - Country:US
Mailing Address - Phone:586-646-5665
Mailing Address - Fax:
Practice Address - Street 1:57731 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048-2627
Practice Address - Country:US
Practice Address - Phone:586-646-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist