Provider Demographics
NPI:1770722043
Name:WALLACE-ROSS, JILL AMY (DO)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:AMY
Last Name:WALLACE-ROSS
Suffix:
Gender:F
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:3200 S. UNIVERSITY DRIVE
Mailing Address - Street 2:ASSEMBLY BLDG. # 2 ROOM 202
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-4343
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:3200 S. UNIVERSITY DRIVE
Practice Address - Street 2:SANFORD L. ZIFF BLDG.
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-4100
Practice Address - Fax:954-262-2271
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2012-02-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine