1215917117 NPI number — MS. JACKIE M. GRISSOM LCMHC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215917117 NPI number — MS. JACKIE M. GRISSOM LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRISSOM
Provider First Name:
JACKIE
Provider Middle Name:
M.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRISSOM
Provider Other First Name:
JACQUALYN
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1215917117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 CALLE CALMADO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-905-5201
Provider Business Mailing Address Fax Number:
704-612-7043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6001 GATEWAY CENTER DR.
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
KANNAPOLIS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-905-5201
Provider Business Practice Location Address Fax Number:
704-612-7043
Provider Enumeration Date:
01/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2798 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6102673 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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