Healthcare Provider Details

I. General information

NPI: 1275229072
Provider Name (Legal Business Name): JEFFREY ALLISON GRIMES L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 S 12TH ST
SAINT LOUIS MO
63104-4321
US

IV. Provider business mailing address

2526 S 12TH ST
SAINT LOUIS MO
63104-4321
US

V. Phone/Fax

Practice location:
  • Phone: 314-440-6533
  • Fax:
Mailing address:
  • Phone: 314-440-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number01886
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: