Provider Demographics
NPI:1528109154
Name:GROSS, JEANICE F (MFT)
Entity type:Individual
Prefix:MS
First Name:JEANICE
Middle Name:F
Last Name:GROSS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 CANARY CT
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1302
Mailing Address - Country:US
Mailing Address - Phone:760-744-4078
Mailing Address - Fax:
Practice Address - Street 1:4407 MANCHESTER AVE
Practice Address - Street 2:,
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4900
Practice Address - Country:US
Practice Address - Phone:760-436-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18887106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist