Provider Demographics
NPI:1881455012
Name:JACLYN ROSS PHD PLLC
Entity type:Organization
Organization Name:JACLYN ROSS PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-210-0374
Mailing Address - Street 1:2333 W SAINT PAUL AVE APT 133
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5343
Mailing Address - Country:US
Mailing Address - Phone:908-246-5028
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 336
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3688
Practice Address - Country:US
Practice Address - Phone:708-665-4721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health