Healthcare Provider Details

I. General information

NPI: 1447967856
Provider Name (Legal Business Name): JEFFREY GRISHAM PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CA SUBSTANCE ABUSE TREATMENT FACILITY & STATE PRISION 900 QUEBEC AVENUE
CORCORAN CA
93212-9321
US

IV. Provider business mailing address

PO BOX 125
CORCORAN CA
93212-0125
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-7100
  • Fax:
Mailing address:
  • Phone: 209-581-1779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: