Provider Demographics
NPI:1316190986
Name:GRISMER, JENNIFER JACKSON (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JACKSON
Last Name:GRISMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BERWICK AVE
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-1646
Mailing Address - Country:US
Mailing Address - Phone:845-778-8502
Mailing Address - Fax:
Practice Address - Street 1:12 BERWICK AVE
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586-1646
Practice Address - Country:US
Practice Address - Phone:845-778-8502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0712911041C0700X
MI68010620591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical