Provider Information for 1790168599
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JEANETTE GRISSOM
Sex: Female
NPI: 1790168599
Last Updated: 2020-11-09
Certification Date: 2020-11-09
Certification Date: 2020-11-09
Details
| Name | Value | ||||||||||||||
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| NPI | 1790168599 | ||||||||||||||
| Enumeration Date | 2015-06-30 | ||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||
| Sole Proprietor | YES | ||||||||||||||
| Status | Active | ||||||||||||||
| Mailing Address | 6626 W 75TH STREET STE 500 INDIANAPOLIS, IN 46250-2890 United States Phone: | Fax: | ||||||||||||||
| Primary Practice Address | 6950 HILLSDALE CT INDIANAPOLIS, IN 46250-2040 United States Phone: 317-621-7740 | Fax:317-621-7608 | ||||||||||||||
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