Provider Demographics
NPI:1558902940
Name:GRUBBS, JODY (MHP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:GRUBBS
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 N WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6295
Mailing Address - Country:US
Mailing Address - Phone:252-702-7838
Mailing Address - Fax:618-242-1150
Practice Address - Street 1:4110 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6295
Practice Address - Country:US
Practice Address - Phone:224-283-8876
Practice Address - Fax:360-718-8542
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WACB60975961106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health