Healthcare Provider Details

I. General information

NPI: 1275818692
Provider Name (Legal Business Name): JENIFER ANN GRISSOM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date: 03/21/2023
Reactivation Date: 04/03/2023

III. Provider practice location address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

IV. Provider business mailing address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-9307
  • Fax:
Mailing address:
  • Phone: 218-829-9307
  • Fax: 218-829-7649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10032
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number16370
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA105481
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: