Provider Demographics
NPI:1356515811
Name:GROSSMAN, JASON T (PHD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:T
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EL CAMINO REAL SUITE 120 #1033
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4884
Mailing Address - Country:US
Mailing Address - Phone:650-204-1246
Mailing Address - Fax:
Practice Address - Street 1:700 EL CAMINO REAL SUITE 120 #1033
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4884
Practice Address - Country:US
Practice Address - Phone:650-204-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2024-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35240103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical