Provider Demographics
NPI:1780475277
Name:GRISSOM, JERALD DEAN III
Entity type:Individual
Prefix:MR
First Name:JERALD
Middle Name:DEAN
Last Name:GRISSOM
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 WEEPING WILLOW DR APT B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3938
Mailing Address - Country:US
Mailing Address - Phone:919-709-5694
Mailing Address - Fax:
Practice Address - Street 1:306 LIBERTY VIEW LN
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2291
Practice Address - Country:US
Practice Address - Phone:434-592-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP530638146M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate