Basic Information
Provider Information | |||||||||
NPI: | 1639341555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3543 SW 30TH WAY | ||||||||
Address2: | #107 | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326082751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2178276158 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 911 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | TRENTON | ||||||||
State: | FL | ||||||||
PostalCode: | 326933239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3524632374 | ||||||||
FaxNumber: | 3524632726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2008 | ||||||||
LastUpdateDate: | 03/31/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME 109165 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 004242600 | 05 | FL |   | MEDICAID | 14J57 | 01 | FL | BCBSFL | OTHER |