Provider Demographics
NPI:1497931372
Name:GRIFFIN, JACQUELYN M (MSW, LISW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MDG
Mailing Address - Street 2:4881 SUGER MAPLE DR.
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-6639
Mailing Address - Fax:
Practice Address - Street 1:88 MDG
Practice Address - Street 2:4881 SUGER MAPLE DR.
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-6639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.17002091041C0700X
OHS-00289791041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool