Provider Demographics
NPI:1699312785
Name:GRIMM, JADIE GAIL MALARK (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JADIE
Middle Name:GAIL MALARK
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JADIE
Other - Middle Name:GAIL
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8020 PARELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-4562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3960 COON RAPIDS BLVD NW STE 123
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2521
Practice Address - Country:US
Practice Address - Phone:763-236-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-08
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-2653235Z00000X
NVSP-2858235Z00000X
MN528701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist