Provider Demographics
NPI:1114641693
Name:GROLL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GROLL
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 1:109 S MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:WY
Mailing Address - Zip Code:82937-5177
Mailing Address - Country:US
Mailing Address - Phone:307-787-3278
Mailing Address - Fax:
Practice Address - Street 1:109 S MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:WY
Practice Address - Zip Code:82937-5177
Practice Address - Country:US
Practice Address - Phone:307-787-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1594225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist