Provider Demographics
NPI:1780117507
Name:GRIMM, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRIMM
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 1:5455 ALMIRA DR NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8330
Mailing Address - Country:US
Mailing Address - Phone:360-415-6690
Mailing Address - Fax:
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8330
Practice Address - Country:US
Practice Address - Phone:360-415-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61153728171M00000X
WA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker