Provider Demographics
NPI:1194563676
Name:GRIMM, JENNIFER L
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GRIMM
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7243 BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:ARPIN
Mailing Address - State:WI
Mailing Address - Zip Code:54410-9527
Mailing Address - Country:US
Mailing Address - Phone:715-221-8918
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-221-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13434-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist