Healthcare Provider Details

I. General information

NPI: 1306543103
Provider Name (Legal Business Name): JESSELYN GRIMSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 30TH ST
DES MOINES IA
50310-5753
US

IV. Provider business mailing address

1209 WALL AVE
DES MOINES IA
50315-5066
US

V. Phone/Fax

Practice location:
  • Phone: 515-699-5999
  • Fax:
Mailing address:
  • Phone: 515-509-4533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: