Provider Demographics
NPI:1528606571
Name:GROSS, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
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 1:301 W 110TH ST APT 6L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-4061
Mailing Address - Country:US
Mailing Address - Phone:917-734-0434
Mailing Address - Fax:
Practice Address - Street 1:10470 QUEENS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3694
Practice Address - Country:US
Practice Address - Phone:718-275-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)