MEDICARE: MR. JEREMY ALAN GROSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant

General Provider Information

NPI Number	:	1013489525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY ALAN GROSS

Provider Business Mailing Address
First Line	:	1203 W ALEXANDER RD APT 5
Second Line	:
City	:	VALLEY GROVE
State	:	WV
Zip	:	26060-8093
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1203 W ALEXANDER RD APT 5
Second Line	:
City	:	VALLEY GROVE
State	:	WV
Zip	:	26060-8093
Country	:	US
Telephone Number	:	304-280-7191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2018
Last Update Date	:	12/21/2018

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