MEDICARE: JENNIFER ANNE GROS PA-C

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	363AM0700X	Medical Physician Assistant	PA17437	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17437	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1558466219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER ANNE GROS PA-C

Provider Business Mailing Address
First Line	:	23371 MULHOLLAND DR STE 343
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-2734
Country	:	US
Telephone Number	:	310-621-3502
Fax Number	:

Provider Business Practice Location Address
First Line	:	23371 MULHOLLAND DR STE 343
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-2734
Country	:	US
Telephone Number	:	310-621-3502
Fax Number	:

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	03/07/2023

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