Provider Demographics
NPI:1912606013
Name:GRUPP, JESSICA NICOLE
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:NICOLE
Last Name:GRUPP
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 1:1225 VAL GENES RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-6044
Mailing Address - Country:US
Mailing Address - Phone:405-850-5441
Mailing Address - Fax:
Practice Address - Street 1:1225 VAL GENES RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-6044
Practice Address - Country:US
Practice Address - Phone:405-850-5441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty