Provider Demographics
NPI:1215917117
Name:GRISSOM, JACKIE M (LCMHC)
Entity type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:M
Last Name:GRISSOM
Suffix:
Gender:
Credentials:LCMHC
Other - Prefix:
Other - First Name:JACQUALYN
Other - Middle Name:M
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:905 CALLE CALMADO
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007
Mailing Address - Country:US
Mailing Address - Phone:704-905-5201
Mailing Address - Fax:704-612-7043
Practice Address - Street 1:6001 GATEWAY CENTER DR.
Practice Address - Street 2:SUITE 105
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081
Practice Address - Country:US
Practice Address - Phone:704-905-5201
Practice Address - Fax:704-612-7043
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2798101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102673Medicaid