Provider Demographics
NPI:1942419544
Name:LIFSHUTZ-GRINBERG, JESSICA BETH (CPO)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:BETH
Last Name:LIFSHUTZ-GRINBERG
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1738
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-1738
Mailing Address - Country:US
Mailing Address - Phone:707-937-6267
Mailing Address - Fax:707-937-1967
Practice Address - Street 1:84 MADRONE ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4249
Practice Address - Country:US
Practice Address - Phone:707-937-3003
Practice Address - Fax:707-937-6267
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1667224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5724280001Medicare NSC