Provider Demographics
NPI:1265803589
Name:ROSS, JEREMY (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23664-1834
Mailing Address - Country:US
Mailing Address - Phone:757-778-7470
Mailing Address - Fax:
Practice Address - Street 1:58 BEACH RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23664-1834
Practice Address - Country:US
Practice Address - Phone:757-778-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102912101YA0400X
VA0701006303101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)