Provider Demographics
NPI:1780212118
Name:GROM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 LOCUST RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-3332
Mailing Address - Country:US
Mailing Address - Phone:914-747-3014
Mailing Address - Fax:
Practice Address - Street 1:759 CHESTNUT ST RM S2575
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-0001
Practice Address - Country:US
Practice Address - Phone:413-794-3998
Practice Address - Fax:413-794-4588
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program