Provider Demographics
NPI:1720334568
Name:GROSSMAN, JENNIFER D (MS)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:D
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-2328
Mailing Address - Country:US
Mailing Address - Phone:631-241-0556
Mailing Address - Fax:
Practice Address - Street 1:597 3RD AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-2509
Practice Address - Country:US
Practice Address - Phone:518-233-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113182174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist