Healthcare Provider Details

I. General information

NPI: 1083361117
Provider Name (Legal Business Name): JESSICA D GROOMES-CARMONA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8626 LOWER SACRAMENTO RD
STOCKTON CA
95210-1834
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-2487
  • Fax:
Mailing address:
  • Phone: 209-468-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number721889
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number721889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: