Provider Demographics
NPI:1629451869
Name:GROSS, JENNA (NP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 19TH ST S STE 101
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2154
Mailing Address - Country:US
Mailing Address - Phone:320-230-7788
Mailing Address - Fax:320-230-7789
Practice Address - Street 1:166 19TH ST S STE 101
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-230-7788
Practice Address - Fax:320-230-7789
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 199200-7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner