Provider Demographics
NPI:1093359838
Name:GROSS, JEFFREY BRIAN (CDCA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BRIAN
Last Name:GROSS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELIZABETH PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3445
Mailing Address - Country:US
Mailing Address - Phone:937-813-3717
Mailing Address - Fax:937-813-4834
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-813-3717
Practice Address - Fax:937-813-4834
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172001101YA0400X
OH174666101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)