Provider Demographics
NPI:1447304639
Name:CHRISTY-GRIMM, JENNIFER (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:CHRISTY-GRIMM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 PARK PL W STE 200
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3587
Mailing Address - Country:US
Mailing Address - Phone:574-271-8646
Mailing Address - Fax:574-271-8624
Practice Address - Street 1:3555 PARK PL W STE 200
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3587
Practice Address - Country:US
Practice Address - Phone:574-271-8646
Practice Address - Fax:574-271-8624
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007232A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200580CMedicare ID - Type Unspecified