Provider Demographics
NPI:1235971987
Name:GRUBB, JESSICA LYNN (LCSWA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GRUBB
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5203
Mailing Address - Country:US
Mailing Address - Phone:704-335-2760
Mailing Address - Fax:
Practice Address - Street 1:1201 WOODRDG CTR DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1988
Practice Address - Country:US
Practice Address - Phone:704-335-2760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0191411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical