Healthcare Provider Details

I. General information

NPI: 1770729998
Provider Name (Legal Business Name): ANGELA KIM GRISSOM SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM TIDWELL

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 N. FLAG CHAPEL ROAD
JACKSON MS
39209
US

IV. Provider business mailing address

147 PECAN HILL DR
CLINTON MS
39056-5233
US

V. Phone/Fax

Practice location:
  • Phone: 601-922-5530
  • Fax: 601-922-5534
Mailing address:
  • Phone: 601-862-9265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS2357
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: