Provider Demographics
NPI:1245343870
Name:GRISWOLD, JENNIFER S (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 NE 3RD ST STE 3-301
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4700
Mailing Address - Country:US
Mailing Address - Phone:541-716-0113
Mailing Address - Fax:
Practice Address - Street 1:1018 SW EMKAY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1010
Practice Address - Country:US
Practice Address - Phone:541-716-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP10774363L00000X
OR200950013NP363L00000X
OR202111832NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604912Medicaid
CANP10774OtherLICENSE
OR500604912Medicaid