Jackie M. Grissom, LCMHC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

2798 Issued in NC

Practice address

6001 Gateway Center Dr.
Suite 105
Kannapolis, NC 28081

Phone

(704) 905-5201

Fax

(704) 612-7043

NPI assigned

Jan 18, 2006

Last updated

Feb 26, 2025By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Jacqualyn M. Grissom Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Previously, effective Sep 1, 2024 through Sep 1, 2026

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1137542400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1740528000000",
    "number": "1215917117",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "905 CALLE CALMADO",
            "city": "LAS CRUCES",
            "state": "NM",
            "postal_code": "88007",
            "telephone_number": "704-905-5201",
            "fax_number": "704-612-7043"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6001 GATEWAY CENTER DR.",
            "address_2": "SUITE 105",
            "city": "KANNAPOLIS",
            "state": "NC",
            "postal_code": "28081",
            "telephone_number": "704-905-5201",
            "fax_number": "704-612-7043"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GRISSOM",
        "first_name": "JACKIE",
        "middle_name": "M.",
        "name_prefix": "Ms.",
        "credential": "LCMHC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-01-18",
        "last_updated": "2025-02-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "NC",
            "license": "2798",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6102673",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACQUALYN",
            "last_name": "GRISSOM",
            "middle_name": "M.",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Professional Counselor in Kannapolis, NC
• Providers in Kannapolis, NC by specialty
• Professional Counselor in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 26, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.