Provider Demographics
NPI:1336344456
Name:GRIZZARD, JENNIFER BENSON (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BENSON
Last Name:GRIZZARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W BANKHEAD HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1736
Mailing Address - Country:US
Mailing Address - Phone:678-941-3868
Mailing Address - Fax:678-941-3217
Practice Address - Street 1:514 W BANKHEAD HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1736
Practice Address - Country:US
Practice Address - Phone:678-941-3868
Practice Address - Fax:678-941-3217
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004238101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA839556035BMedicaid