Provider Demographics
NPI:1720865488
Name:GROSS, JEFFREY WILLIAM (SAC-IT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:GROSS
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1557 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3920
Mailing Address - Country:US
Mailing Address - Phone:715-330-6272
Mailing Address - Fax:
Practice Address - Street 1:1557 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3920
Practice Address - Country:US
Practice Address - Phone:715-330-6272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20388-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)