Provider Demographics
NPI:1568422616
Name:GROTH, JESSICA J (DPT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:J
Last Name:GROTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 E FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6277
Mailing Address - Country:US
Mailing Address - Phone:269-352-7899
Mailing Address - Fax:
Practice Address - Street 1:2764 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6277
Practice Address - Country:US
Practice Address - Phone:269-352-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL2451174400000X
FLPT30765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist