Provider Demographics
NPI:1437759651
Name:CHRISTOPHER, JACK ROSS
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROSS
Last Name:CHRISTOPHER
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 1:455 22ND ST E UNIT B
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2392
Mailing Address - Country:US
Mailing Address - Phone:701-809-8571
Mailing Address - Fax:
Practice Address - Street 1:455 22ND ST E UNIT B
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-2392
Practice Address - Country:US
Practice Address - Phone:701-809-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant