Provider Demographics
NPI:1851668198
Name:ROSS, JOLENE (LMP)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18355 N RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-7509
Mailing Address - Country:US
Mailing Address - Phone:208-290-2409
Mailing Address - Fax:
Practice Address - Street 1:18355 N RAMSEY RD
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-7509
Practice Address - Country:US
Practice Address - Phone:208-290-2409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022516225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist