Provider Demographics
NPI:1740823343
Name:GROOM, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GROOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BUTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-5624
Mailing Address - Country:US
Mailing Address - Phone:508-759-1190
Mailing Address - Fax:
Practice Address - Street 1:16 BRIDGE GATE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-6377
Practice Address - Country:US
Practice Address - Phone:508-287-8692
Practice Address - Fax:508-591-7886
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician