Provider Demographics
NPI:1972936524
Name:GROTFELDT, JESSICA ANNE (LAC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANNE
Last Name:GROTFELDT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 E FORT LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1100
Mailing Address - Country:US
Mailing Address - Phone:832-545-1254
Mailing Address - Fax:
Practice Address - Street 1:929 N JACOBUS AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7846
Practice Address - Country:US
Practice Address - Phone:832-545-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005084-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist