Basic Information
| Provider Information | |||||||||
| NPI: | 1285796664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAFARIK-GRIMMIG | ||||||||
| FirstName: | JANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381262023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015770200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 427 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381262023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015770200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 13181 | TN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3190405 | 05 | TN | MEDICAID |