Healthcare Provider Details

I. General information

NPI: 1407370356
Provider Name (Legal Business Name): JENNIFER L GRIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 WILLOW STREET PIKE N
WILLOW STREET PA
17584-9510
US

IV. Provider business mailing address

2605 WILLOW STREET PIKE N
WILLOW STREET PA
17584-9510
US

V. Phone/Fax

Practice location:
  • Phone: 717-464-2838
  • Fax: 717-464-3812
Mailing address:
  • Phone: 717-464-2838
  • Fax: 717-464-3812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP017534
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: