Provider Demographics
NPI:1376006890
Name:GROSS, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:711 N 36TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2977
Practice Address - Country:US
Practice Address - Phone:816-271-4022
Practice Address - Fax:816-271-4020
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7126207Q00000X
MO2022029081207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine