Provider Demographics
NPI:1902283336
Name:GROSS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3161 CUSTER DR STE 4
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4067
Mailing Address - Country:US
Mailing Address - Phone:859-977-6080
Mailing Address - Fax:859-977-4502
Practice Address - Street 1:3161 CUSTER DR STE 4
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4067
Practice Address - Country:US
Practice Address - Phone:859-977-6080
Practice Address - Fax:859-977-4502
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00218578101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid