Provider Demographics
NPI:1033533922
Name:ROSS, JACQUELINE DIANE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DIANE
Last Name:ROSS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 PLEASANT FOREST DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2214
Mailing Address - Country:US
Mailing Address - Phone:479-200-0417
Mailing Address - Fax:
Practice Address - Street 1:12509 PLEASANT FOREST DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-2214
Practice Address - Country:US
Practice Address - Phone:479-200-0417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT 6042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer