MEDICARE: DR. JESSICA JEAN GRIMM O.D.

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	152W00000X	Optometrist	6743T	TX
2	152W00000X	Optometrist	6743TG	TX

General Provider Information

NPI Number	:	1407858962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA JEAN GRIMM O.D.

Provider Business Mailing Address
First Line	:	5619 W LOOP 1604 N STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-5795
Country	:	US
Telephone Number	:	210-792-3089
Fax Number	:

Provider Business Practice Location Address
First Line	:	5619 W LOOP 1604 N STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-5795
Country	:	US
Telephone Number	:	210-792-3089
Fax Number	:

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	05/10/2024

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