Healthcare Provider Details

I. General information

NPI: 1831570225
Provider Name (Legal Business Name): JENNA NICOLE GRINDLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45280 SEELEY DR FL 2
LA QUINTA CA
92253
US

IV. Provider business mailing address

45280 SEELEY DR FL 2
LA QUINTA CA
92253-6834
US

V. Phone/Fax

Practice location:
  • Phone: 760-834-7920
  • Fax: 760-834-7921
Mailing address:
  • Phone: 760-834-7920
  • Fax: 760-834-7921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA151053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: