Provider Demographics
NPI:1780944314
Name:GRASS, JESSICA LYNN (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GRASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:4235 S NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-8453
Practice Address - Country:US
Practice Address - Phone:704-825-4750
Practice Address - Fax:704-825-6985
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC182781207Q00000X
NC2015-00273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19DJ7OtherBCBS OF NC
NC1780944314Medicaid