Provider Demographics
NPI:1982801288
Name:GROVE, JASON CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CHARLES
Last Name:GROVE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 BERNARD DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4357
Mailing Address - Country:US
Mailing Address - Phone:540-728-1570
Mailing Address - Fax:
Practice Address - Street 1:5115 BERNARD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4357
Practice Address - Country:US
Practice Address - Phone:540-728-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116019726390200000X
VA01022028322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982801288Medicaid
VA1982801288Medicaid