Basic Information
| Provider Information | |||||||||
| NPI: | 1013541069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | PORTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15577 NORTHVILLE FOREST DR APT 222 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2672186264 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2145 N FAIRFIELD RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454312783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375583900 | ||||||||
| FaxNumber: | 9375583999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2020 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.