Provider Demographics
NPI:1417449018
Name:ROSS, JESSICA ANNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 880926
Mailing Address - Street 2:
Mailing Address - City:PUKALANI
Mailing Address - State:HI
Mailing Address - Zip Code:96788-0926
Mailing Address - Country:US
Mailing Address - Phone:808-866-6512
Mailing Address - Fax:
Practice Address - Street 1:55 KUAU BEACH PL
Practice Address - Street 2:
Practice Address - City:PAIA
Practice Address - State:HI
Practice Address - Zip Code:96779-8121
Practice Address - Country:US
Practice Address - Phone:808-214-2992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI76910163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse