Provider Demographics
NPI:1104664036
Name:GRUBOY, JESSICA (MHC-LP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GRUBOY
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 FLATBUSH AVE UNIT 340152
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4530
Mailing Address - Country:US
Mailing Address - Phone:347-201-0868
Mailing Address - Fax:
Practice Address - Street 1:2222 FLATBUSH AVE UNIT 340152
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4530
Practice Address - Country:US
Practice Address - Phone:347-201-0868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P129649-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health