Provider Demographics
NPI:1164464657
Name:GRUMET, JENNIFER BROOKE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BROOKE
Last Name:GRUMET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BROOKE
Other - Last Name:MCCONICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23781 MAQUINA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2716
Mailing Address - Country:US
Mailing Address - Phone:213-445-5824
Mailing Address - Fax:
Practice Address - Street 1:23781 MAQUINA
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2716
Practice Address - Country:US
Practice Address - Phone:213-445-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11810Medicare ID - Type UnspecifiedGROUP NUMBER