Provider Demographics
NPI:1942795521
Name:GROSS, JEFFERY ROBERT (PTA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ROBERT
Last Name:GROSS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 GROSS LOOP
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-8625
Mailing Address - Country:US
Mailing Address - Phone:606-272-1969
Mailing Address - Fax:
Practice Address - Street 1:1376 SILVER SPRINGS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2319
Practice Address - Country:US
Practice Address - Phone:859-277-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02416225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherN/A