Basic Information
Provider Information | |||||||||
NPI: | 1588969554 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | A-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4801 TROUP HWY | ||||||||
Address2: | SUITE 800 | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757032356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9039392800 | ||||||||
FaxNumber: | 9035817057 | ||||||||
Practice Location | |||||||||
Address1: | 4801 TROUP HWY | ||||||||
Address2: | SUITE 800 | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757032356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9039392800 | ||||||||
FaxNumber: | 9035817057 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/21/2011 | ||||||||
LastUpdateDate: | 01/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 106437 | TX | Y |   | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
ID | Type | State | Issuer | Description | 207164901 | 05 | TX |   | MEDICAID | 149984001 | 05 | TX |   | MEDICAID |