Provider Demographics
NPI:1669595708
Name:GROCE, JACQUELINE A (OTR)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:A
Last Name:GROCE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 BRETON HUNT LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3874
Mailing Address - Country:US
Mailing Address - Phone:678-482-6040
Mailing Address - Fax:
Practice Address - Street 1:2155 W PARK CT
Practice Address - Street 2:SUITE G
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3500
Practice Address - Country:US
Practice Address - Phone:770-465-5084
Practice Address - Fax:770-465-5304
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003908225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist