MEDICARE: JEFFREY SCOTT GRIMES PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	33564	TX

General Provider Information

NPI Number	:	1023207321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY SCOTT GRIMES PHD

Provider Business Mailing Address
First Line	:	5625 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5719
Country	:	US
Telephone Number	:	210-621-3462
Fax Number	:	210-822-7466

Provider Business Practice Location Address
First Line	:	5625 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5719
Country	:	US
Telephone Number	:	210-621-3462
Fax Number	:	210-822-7466

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2007
Last Update Date	:	09/30/2009

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