Provider Demographics
NPI:1740909159
Name:GRANT, JESSICA (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2700
Mailing Address - Country:US
Mailing Address - Phone:814-254-8709
Mailing Address - Fax:
Practice Address - Street 1:312 OLIVE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2700
Practice Address - Country:US
Practice Address - Phone:814-254-8709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN316108164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse