Provider Demographics
NPI:1942964192
Name:GRIMM, JORDAN P
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:P
Last Name:GRIMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10703 N GLENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9771
Mailing Address - Country:US
Mailing Address - Phone:815-878-0334
Mailing Address - Fax:
Practice Address - Street 1:4481 ASH GROVE DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6359
Practice Address - Country:US
Practice Address - Phone:309-693-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178019034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional