Provider Demographics
NPI:1265860316
Name:AMY CATHERINE JACKSON-GROSSBLAT
Entity Type:Organization
Organization Name:AMY CATHERINE JACKSON-GROSSBLAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:JACKSON-GROSSBLAT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-208-0002
Mailing Address - Street 1:5646 E MORNING VISTA LN
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-3446
Mailing Address - Country:US
Mailing Address - Phone:269-208-0002
Mailing Address - Fax:480-275-2598
Practice Address - Street 1:5646 E MORNING VISTA LN
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-3446
Practice Address - Country:US
Practice Address - Phone:269-208-0002
Practice Address - Fax:480-275-2598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty