Basic Information
| Provider Information | |||||||||
| NPI: | 1245343870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISWOLD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413822811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1080 MOUNT BACHELOR DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415504400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 03/31/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP10774 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 200950013NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500604912 | 05 | OR | MEDICAID | NP10774 | 01 | CA | LICENSE | OTHER |