Provider Demographics
NPI:1376567297
Name:ROSS, JEANNETTE D (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:D
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:D
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1730 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-6424
Mailing Address - Country:US
Mailing Address - Phone:941-223-0105
Mailing Address - Fax:941-681-2663
Practice Address - Street 1:1460 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4864
Practice Address - Country:US
Practice Address - Phone:941-223-0105
Practice Address - Fax:941-681-2663
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00021471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2818AOtherPTAN
FLZ2818OtherBLUE CROSS BLUE SHIELD
FL1105340OtherCIGNA BEHAV HEALTH
FL689672396Medicaid