Provider Demographics
NPI:1265089973
Name:GRANT, JEFF CLINTON (CDPT)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:CLINTON
Last Name:GRANT
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 CYRENE DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-3008
Mailing Address - Country:US
Mailing Address - Phone:425-583-8733
Mailing Address - Fax:
Practice Address - Street 1:235 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2255
Practice Address - Country:US
Practice Address - Phone:360-426-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2023-09-28
Deactivation Date:2023-02-08
Deactivation Code:
Reactivation Date:2023-09-28
Provider Licenses
StateLicense IDTaxonomies
WACO60944500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)