Provider Demographics
NPI:1417458076
Name:LICHTIG-GROOM, JESSICA HOLLY (DOULA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:HOLLY
Last Name:LICHTIG-GROOM
Suffix:
Gender:F
Credentials:DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11885 FROND RD
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-2153
Mailing Address - Country:US
Mailing Address - Phone:530-574-8030
Mailing Address - Fax:
Practice Address - Street 1:11885 FROND RD
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-2153
Practice Address - Country:US
Practice Address - Phone:530-574-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
NV374J00000X
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174H00000XOther Service ProvidersHealth Educator