Healthcare Provider Details

I. General information

NPI: 1699658476
Provider Name (Legal Business Name): DANIELLE JANSEN GRISSOM PPS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10293 BLOOMFIELD ST
LOS ALAMITOS CA
90720-2264
US

IV. Provider business mailing address

10293 BLOOMFIELD ST
LOS ALAMITOS CA
90720-2264
US

V. Phone/Fax

Practice location:
  • Phone: 562-799-4700
  • Fax:
Mailing address:
  • Phone: 562-799-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number240169424
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: