Healthcare Provider Details

I. General information

NPI: 1073436341
Provider Name (Legal Business Name): JESSICA GROTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 SAINT JOE CENTER RD STE 23
FORT WAYNE IN
46825-5000
US

IV. Provider business mailing address

1910 SAINT JOE CENTER RD STE 23
FORT WAYNE IN
46825-5000
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-5599
  • Fax:
Mailing address:
  • Phone: 260-484-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39006115A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: