Provider Demographics
NPI:1134632078
Name:ROSS, JESSICA ANN (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:ROSS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:BARKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:645 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-2204
Mailing Address - Country:US
Mailing Address - Phone:126-272-3496
Mailing Address - Fax:
Practice Address - Street 1:645 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-2204
Practice Address - Country:US
Practice Address - Phone:126-272-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5389-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty