Provider Demographics
NPI:1326252495
Name:GROFF, JESSICA ROSE (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:GROFF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23505 SMITHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1750
Mailing Address - Country:US
Mailing Address - Phone:952-470-8555
Mailing Address - Fax:952-401-8785
Practice Address - Street 1:23505 SMITHTOWN RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-1750
Practice Address - Country:US
Practice Address - Phone:952-470-8555
Practice Address - Fax:952-401-8785
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650001784Medicare PIN