Healthcare Provider Details

I. General information

NPI: 1902727829
Provider Name (Legal Business Name): JENNIFER S GROSSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3387 S 115TH ST
OMAHA NE
68144-4612
US

IV. Provider business mailing address

3387 S 115TH ST
OMAHA NE
68144-4612
US

V. Phone/Fax

Practice location:
  • Phone: 612-961-4780
  • Fax:
Mailing address:
  • Phone: 612-961-4780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: