=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861110272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAYCI GRISAFE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2022
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 438 CAMINO DEL RIO S STE 106
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-895-8090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 E. WILLOW ST. #D - PMB 273
-----------------------------------------------------
City | SIGNAL HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 22327
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------