Provider Demographics
NPI:1477214476
Name:GRIMES, JASON FAIRLEY
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:FAIRLEY
Last Name:GRIMES
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 1:2290 KERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-2593
Mailing Address - Country:US
Mailing Address - Phone:910-322-3437
Mailing Address - Fax:
Practice Address - Street 1:2290 KERFIELD CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-2593
Practice Address - Country:US
Practice Address - Phone:910-322-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6361225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant