Basic Information
| Provider Information | |||||||||
| NPI: | 1780944314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRASS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744786 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342450 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Practice Location | |||||||||
| Address1: | 4235 S NEW HOPE RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280568453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048254750 | ||||||||
| FaxNumber: | 7048256985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 182781 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2015-00273 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 19DJ7 | 01 | NC | BCBS OF NC | OTHER | 1780944314 | 05 | NC | MEDICAID |