Provider Demographics
NPI:1275818692
Name:GRISSOM, JENIFER ANN (CNP)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:ANN
Last Name:GRISSOM
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:513-791-7046
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:302 NE 14TH ST
Practice Address - Street 2:
Practice Address - City:LEON
Practice Address - State:IA
Practice Address - Zip Code:50144-1206
Practice Address - Country:US
Practice Address - Phone:641-446-2383
Practice Address - Fax:641-446-2382
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2025-04-16
Deactivation Date:2023-03-21
Deactivation Code:
Reactivation Date:2023-04-03
Provider Licenses
StateLicense IDTaxonomies
IAA105481363LF0000X
IL209025330363LP0808X
WI16370364SP0808X
MN10032363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health