Provider Demographics
NPI:1093178006
Name:ROSS, JEREMY DANIEL
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S PINE ST APT J134
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6444
Mailing Address - Country:US
Mailing Address - Phone:253-353-1443
Mailing Address - Fax:
Practice Address - Street 1:11582 C ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS-MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-966-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225012164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse