Provider Demographics
NPI:1720174535
Name:GROVES, JENNIFER G (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:GROVES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75420
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5420
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:703-385-1062
Practice Address - Street 1:6301 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4266
Practice Address - Country:US
Practice Address - Phone:817-877-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005261363A00000X
DC363A00000X
KYPA901363A00000X, 363AM0700X
IN99066589A363A00000X
IN10001825B363A00000X
IN10001825A363A00000X
TXPA15632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYASC1019OtherASC MEDICARE
KY4000501OtherMEDICARE LAB GROUP
KY95005351Medicaid
KY37903705OtherMEDICAID LAB GROUP
KYP00379405OtherRR MEDICARE PIN
KYCB5773OtherRR GROUP NO
IN201162650Medicaid
KY36000818OtherASC MEDICAID GROUP
ININ1920014Medicare PIN
IN201162650Medicaid
KY0624483Medicare PIN
KYASC1019OtherASC MEDICARE
KYK094130Medicare PIN
KY0624483Medicare PIN