Provider Demographics
NPI:1700411212
Name:GRUBER, JESSICA KIM (LMFT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KIM
Last Name:GRUBER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 7TH AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3634
Mailing Address - Country:US
Mailing Address - Phone:612-327-8372
Mailing Address - Fax:
Practice Address - Street 1:11 HANOVER SQ FL 27
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-2835
Practice Address - Country:US
Practice Address - Phone:718-568-6974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001521-1106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist