Provider Demographics
NPI:1497073936
Name:GRIMM, JEFFREY (NP-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:GRIMM
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 NW 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:971-770-1655
Mailing Address - Fax:844-364-2677
Practice Address - Street 1:1741 NW 24TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:971-770-1655
Practice Address - Fax:844-364-2677
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050059NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health