Provider Demographics
NPI:1679179865
Name:GRIFFIN, JESSE R
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:GRIFFIN
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 1:9061 LITTLE BROOK ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-4923
Mailing Address - Country:US
Mailing Address - Phone:907-349-2735
Mailing Address - Fax:
Practice Address - Street 1:540 W INTERNATIONAL AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1105
Practice Address - Country:US
Practice Address - Phone:907-561-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator