Provider Demographics
NPI:1265968739
Name:GRISWOLD, JASON (LICSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GRISWOLD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6936 PINE ARBOR DR S STE 200
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4672
Mailing Address - Country:US
Mailing Address - Phone:612-247-0000
Mailing Address - Fax:
Practice Address - Street 1:6936 PINE ARBOR DR S STE 200
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4672
Practice Address - Country:US
Practice Address - Phone:651-461-2903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical