Provider Demographics
NPI:1659055507
Name:GRISSOM, JENNIFER STUART
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:STUART
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:STUART
Other - Last Name:PAPPAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHP-R
Mailing Address - Street 1:6472 ROLLING RUN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5320 BRIDGERS RD STE 4
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4737
Practice Address - Country:US
Practice Address - Phone:910-769-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013796101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health