Provider Demographics
NPI:1376918136
Name:DEGROOT, JESSICA
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:DEGROOT
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:WI
Mailing Address - Zip Code:54155-0365
Mailing Address - Country:US
Mailing Address - Phone:920-490-3790
Mailing Address - Fax:920-490-3845
Practice Address - Street 1:2640 W POINT RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1344
Practice Address - Country:US
Practice Address - Phone:920-490-3790
Practice Address - Fax:920-490-3845
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3315-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689908527Medicaid