Provider Demographics
NPI:1922061043
Name:ROSS, JEANNA M (APN)
Entity Type:Individual
Prefix:MRS
First Name:JEANNA
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-692-0400
Mailing Address - Fax:309-692-2804
Practice Address - Street 1:5401 N KNOXVILLE AVE STE 207
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5021
Practice Address - Country:US
Practice Address - Phone:309-692-0400
Practice Address - Fax:309-692-2804
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005204363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23262Medicare ID - Type Unspecified
P98279Medicare UPIN