Provider Demographics
NPI:1659674109
Name:ROSS, JACQUELINE M (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 LAZY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1939
Mailing Address - Country:US
Mailing Address - Phone:334-819-7913
Mailing Address - Fax:
Practice Address - Street 1:2400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-5001
Practice Address - Country:US
Practice Address - Phone:334-727-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000075901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical