Provider Demographics
NPI:1639120074
Name:GROSSTICK, JENNIFER (AUD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GROSSTICK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 E SHEA BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6042
Mailing Address - Country:US
Mailing Address - Phone:602-264-4834
Mailing Address - Fax:480-214-9929
Practice Address - Street 1:4530 E SHEA BLVD STE 180
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6042
Practice Address - Country:US
Practice Address - Phone:602-264-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA1822237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ64025Medicare ID - Type Unspecified