Provider Demographics
NPI:1134841125
Name:GRISHAM, JESSICA NICOLE (MSN, APRN, WHNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:MSN, APRN, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6477
Mailing Address - Country:US
Mailing Address - Phone:618-997-5266
Mailing Address - Fax:
Practice Address - Street 1:3408 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6477
Practice Address - Country:US
Practice Address - Phone:618-997-5266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025601363LW0102X
IL041405852163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty