Provider Demographics
NPI:1609037167
Name:GROGG, JAMIE DYAN (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:DYAN
Last Name:GROGG
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 1:4411 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-5349
Mailing Address - Country:US
Mailing Address - Phone:765-674-4455
Mailing Address - Fax:765-674-3577
Practice Address - Street 1:4411 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5349
Practice Address - Country:US
Practice Address - Phone:765-674-4455
Practice Address - Fax:765-674-3577
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009584A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN129137500OtherUS DEPARTMENT OF LABOR
IN100124000Medicaid
IN156540Medicare PIN
IN129137500OtherUS DEPARTMENT OF LABOR