Provider Demographics
NPI:1619391851
Name:ROSS, JAMIE (NP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MICHIGAN AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1580
Mailing Address - Country:US
Mailing Address - Phone:574-722-4921
Mailing Address - Fax:574-739-0520
Practice Address - Street 1:1201 MICHIGAN AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1580
Practice Address - Country:US
Practice Address - Phone:574-722-4921
Practice Address - Fax:574-739-0520
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201214700Medicaid
INP01358162OtherRAILROAD MEDICARE
IN000000879689OtherANTHEM
INP01358162OtherRAILROAD MEDICARE