Provider Demographics
NPI:1356632582
Name:GROSS, JACK EVERETT (EDD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:EVERETT
Last Name:GROSS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CABARRUS AVE E
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3699
Mailing Address - Country:US
Mailing Address - Phone:888-849-7379
Mailing Address - Fax:855-857-7333
Practice Address - Street 1:101 CABARRUS AVE E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3699
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13823183500000X
NC1738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No183500000XPharmacy Service ProvidersPharmacist