Basic Information
| Provider Information | |||||||||
| NPI: | 1164083747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 JACQUES AVE | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088601000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2019 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 903385 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | RN2362912 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.