Provider Demographics
NPI:1386340453
Name:GRIMM, JESSICA (CT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GRIMM
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8590 EVERGREEN TRL APT 312
Mailing Address - Street 2:
Mailing Address - City:OLMSTED TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44138-4285
Mailing Address - Country:US
Mailing Address - Phone:440-915-4431
Mailing Address - Fax:
Practice Address - Street 1:2100 LAKESIDE AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1126
Practice Address - Country:US
Practice Address - Phone:216-566-0047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204344-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health