Provider Demographics
NPI:1265295174
Name:GRANTHAM, JILLIAN ZOFIA
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ZOFIA
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COMMERCE CT
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:615-560-6622
Mailing Address - Fax:
Practice Address - Street 1:17358 GA-67
Practice Address - Street 2:158
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-3045
Practice Address - Country:US
Practice Address - Phone:908-752-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician