Provider Demographics
NPI:1588232045
Name:ROSS, JASMIRA IVONTE (LCMHCA)
Entity Type:Individual
Prefix:
First Name:JASMIRA
Middle Name:IVONTE
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N 16TH ST STE 316
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1266
Mailing Address - Country:US
Mailing Address - Phone:602-845-0049
Mailing Address - Fax:
Practice Address - Street 1:309 CRUTCHFIELD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2754
Practice Address - Country:US
Practice Address - Phone:919-560-7305
Practice Address - Fax:919-797-1962
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16060101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA16060OtherLICENSE