Provider Demographics
NPI:1679655054
Name:GRIFFIN, JENNIFER THOMAS (D P M)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:THOMAS
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:D P M
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:203 KINGS ROW
Mailing Address - Street 2:
Mailing Address - City:MALAKOFF
Mailing Address - State:TX
Mailing Address - Zip Code:75148-9358
Mailing Address - Country:US
Mailing Address - Phone:972-971-7085
Mailing Address - Fax:903-489-1070
Practice Address - Street 1:1344 CHEVELLE DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9565
Practice Address - Country:US
Practice Address - Phone:616-274-7258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002666213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612866Medicare PIN