Provider Demographics
NPI:1548459191
Name:GRIMM, JERI BEA (PA)
Entity type:Individual
Prefix:MS
First Name:JERI
Middle Name:BEA
Last Name:GRIMM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:3841 SPRINGLAKE CUTOFF
Mailing Address - Street 2:
Mailing Address - City:HENSLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72065-9317
Mailing Address - Country:US
Mailing Address - Phone:501-526-6159
Mailing Address - Fax:501-686-7285
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-526-6159
Practice Address - Fax:501-686-7285
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2008-03-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARPA-307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5L693P133Medicare PIN