Provider Demographics
NPI:1760638803
Name:GROVER, JESSE
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:GROVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 ADIRONDACK DR
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-3244
Mailing Address - Country:US
Mailing Address - Phone:631-871-2451
Mailing Address - Fax:
Practice Address - Street 1:128 ADIRONDACK DR
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-3244
Practice Address - Country:US
Practice Address - Phone:631-871-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265492-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse