Provider Demographics
NPI:1518027648
Name:ROSS, JESSE BERNARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:BERNARD
Last Name:ROSS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 PITT ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5318
Mailing Address - Country:US
Mailing Address - Phone:843-766-4444
Mailing Address - Fax:843-225-0840
Practice Address - Street 1:123 PITT ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5318
Practice Address - Country:US
Practice Address - Phone:843-766-4444
Practice Address - Fax:843-225-0840
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ300300281Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
SCQ300300281Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
SC74-3029305OtherTAX ID NUMBER
SC743029305OtherBCBS