Healthcare Provider Details

I. General information

NPI: 1215019211
Provider Name (Legal Business Name): JACQUELINE ELIZABETH GROSSE MA, CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7981 168TH AVE NE STE 122
REDMOND WA
98052-0911
US

IV. Provider business mailing address

15585 NE 68TH CT
REDMOND WA
98052-4829
US

V. Phone/Fax

Practice location:
  • Phone: 831-588-2899
  • Fax:
Mailing address:
  • Phone: 831-588-2899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12851
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL00003852
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: