Provider Demographics
NPI:1487971412
Name:GRONBACK, JESSE (MSW, LCSW, PMHNP)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:GRONBACK
Suffix:
Gender:M
Credentials:MSW, LCSW, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 REGENT PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-3727
Mailing Address - Country:US
Mailing Address - Phone:828-505-1762
Mailing Address - Fax:828-505-1763
Practice Address - Street 1:5 KITCHIN PL # 220
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2665
Practice Address - Country:US
Practice Address - Phone:828-505-1762
Practice Address - Fax:828-505-1763
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC007267101YM0800X
NC5017230363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3410049Medicaid