Provider Demographics
NPI:1740823343
Name:GROOM, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GROOM
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 1:402 PLANTATION PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8262
Mailing Address - Country:US
Mailing Address - Phone:774-454-7969
Mailing Address - Fax:
Practice Address - Street 1:4929 DARCY WOODS LN
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7622
Practice Address - Country:US
Practice Address - Phone:919-810-1459
Practice Address - Fax:919-400-4224
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3120103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst