Provider Demographics
NPI:1184165755
Name:ROSS, JERRY (CASAC 2)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:CASAC 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-1015
Mailing Address - Country:US
Mailing Address - Phone:212-690-4625
Mailing Address - Fax:
Practice Address - Street 1:2015 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-1015
Practice Address - Country:US
Practice Address - Phone:212-690-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)