Provider Demographics
NPI:1639806870
Name:ROSS, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 W 500 S
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-7616
Mailing Address - Country:US
Mailing Address - Phone:765-469-4158
Mailing Address - Fax:
Practice Address - Street 1:1101 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1528
Practice Address - Country:US
Practice Address - Phone:574-753-1549
Practice Address - Fax:574-753-1300
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28227008A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily