Provider Demographics
NPI:1518505361
Name:GROM, JENNIFER ANN (MED)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:GROM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5624 WOOD LN
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9547
Mailing Address - Country:US
Mailing Address - Phone:484-553-1858
Mailing Address - Fax:
Practice Address - Street 1:2909 ROUTE 100 STE 110
Practice Address - Street 2:
Practice Address - City:OREFIELD
Practice Address - State:PA
Practice Address - Zip Code:18069-2951
Practice Address - Country:US
Practice Address - Phone:484-264-0916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004741103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst