Basic Information
| Provider Information | |||||||||
| NPI: | 1790168599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISSOM | ||||||||
| FirstName: | JEANETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 W 75TH STREET | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6950 HILLSDALE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217740 | ||||||||
| FaxNumber: | 3176217608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 87000380A | IN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 39000273A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.