Provider Demographics
NPI:1558466219
Name:GROS, JENNIFER ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:GROS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMI
Other - Middle Name:
Other - Last Name:GROS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:23371 MULHOLLAND DR STE 343
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2734
Mailing Address - Country:US
Mailing Address - Phone:310-621-3502
Mailing Address - Fax:
Practice Address - Street 1:23371 MULHOLLAND DR STE 343
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2734
Practice Address - Country:US
Practice Address - Phone:310-621-3502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17437363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17437OtherSTATE LICENSE
CA17437OtherSTATE LICENSE