Provider Demographics
NPI:1770916165
Name:ROSS, JACQUELINE ROCHELLE (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ROCHELLE
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHD
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Mailing Address - Street 1:3612 LINCOLN HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1627
Mailing Address - Country:US
Mailing Address - Phone:708-957-9420
Mailing Address - Fax:708-365-6392
Practice Address - Street 1:1139 LEAVITT AVE
Practice Address - Street 2:UNIT 210
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1550
Practice Address - Country:US
Practice Address - Phone:708-957-9420
Practice Address - Fax:708-365-6392
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL178008975101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional