Provider Demographics
NPI:1750998605
Name:GRIZZARD, JACQUELYN S
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:S
Last Name:GRIZZARD
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 1:11818 97TH LN NE APT C426
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-8974
Mailing Address - Country:US
Mailing Address - Phone:813-966-1223
Mailing Address - Fax:
Practice Address - Street 1:11818 97TH LN NE APT C426
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-8974
Practice Address - Country:US
Practice Address - Phone:813-966-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171R00000XOther Service ProvidersInterpreterGroup - Single Specialty