Basic Information
| Provider Information | |||||||||
| NPI: | 1396151395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRINAGE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN-MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 412 S. MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088355550 | ||||||||
| FaxNumber: | 2088355554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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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 | 363A00000X | PA-1175 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1396151395 | 05 | ID | MEDICAID | 0335238 | 01 | WA | L&I NETWORK | OTHER | 1396151395 | 05 | WA | MEDICAID |