Provider Demographics
NPI:1164083747
Name:ROSS, JENNIFER GAIL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GAIL
Last Name:ROSS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W VAN DORN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-2902
Mailing Address - Country:US
Mailing Address - Phone:662-274-3212
Mailing Address - Fax:662-274-3213
Practice Address - Street 1:72 JACQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-860-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903385363LP0808X
MARN2362912363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health