Provider Demographics
NPI:1639341555
Name:ROSS, JESSICA R (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:R
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 SW 30TH WAY
Mailing Address - Street 2:#107
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-2751
Mailing Address - Country:US
Mailing Address - Phone:217-827-6158
Mailing Address - Fax:
Practice Address - Street 1:911 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:FL
Practice Address - Zip Code:32693-3239
Practice Address - Country:US
Practice Address - Phone:352-463-2374
Practice Address - Fax:352-463-2726
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 109165208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004242600Medicaid
FL14J57OtherBCBSFL
FL004242600Medicaid