Provider Demographics
NPI:1609038009
Name:ROSS, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:COULOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:755 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1607
Mailing Address - Country:US
Mailing Address - Phone:331-221-2900
Mailing Address - Fax:331-221-3883
Practice Address - Street 1:755 N YORK ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1607
Practice Address - Country:US
Practice Address - Phone:331-221-2900
Practice Address - Fax:331-221-3883
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine