Healthcare Provider Details

I. General information

NPI: 1831460971
Provider Name (Legal Business Name): JEANNE ANN GRYMKO L.P.C., C.A.A.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JEANNE ANN DAVENPORT

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E TURNER ST
FORTY FORT PA
18704-4913
US

IV. Provider business mailing address

15 E TURNER ST
FORTY FORT PA
18704-4913
US

V. Phone/Fax

Practice location:
  • Phone: 570-313-6449
  • Fax:
Mailing address:
  • Phone: 570-313-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number010090
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: