Provider Demographics
NPI:1013489525
Name:GROSS, JEREMY ALAN
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ALAN
Last Name:GROSS
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 1:1203 W ALEXANDER RD APT 5
Mailing Address - Street 2:
Mailing Address - City:VALLEY GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26060-8093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 W ALEXANDER RD APT 5
Practice Address - Street 2:
Practice Address - City:VALLEY GROVE
Practice Address - State:WV
Practice Address - Zip Code:26060-8093
Practice Address - Country:US
Practice Address - Phone:304-280-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant