Provider Demographics
NPI:1952308033
Name:GRANDISON, JAYNE A (EDD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:A
Last Name:GRANDISON
Suffix:
Gender:F
Credentials:EDD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7009 W AUGUSTA BLVD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-9330
Mailing Address - Country:US
Mailing Address - Phone:765-759-6160
Mailing Address - Fax:765-759-6160
Practice Address - Street 1:7009 W AUGUSTA BLVD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-9330
Practice Address - Country:US
Practice Address - Phone:765-759-6160
Practice Address - Fax:765-759-6160
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIN#20040030103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000179367OtherANTHEM BC/BS
IN2046272OtherCIGNA
IN2046272OtherCARDINAL CARE
IN2046272OtherCARDINAL CARE