Basic Information
| Provider Information | |||||||||
| NPI: | 1689007502 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JACQUES | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2825 E BARNETT RD | ||||||||
| Address2: | RRMC MED STAFF | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894281 | ||||||||
| FaxNumber: | 5417894806 | ||||||||
| Practice Location | |||||||||
| Address1: | 781 BLACK OSK DR #102 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894236 | ||||||||
| FaxNumber: | 5417895965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12314-24 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 61025 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.