Healthcare Provider Details

I. General information

NPI: 1306792015
Provider Name (Legal Business Name): MRS. JESSICA ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 RIVERCHASE DR
PHENIX CITY AL
36867-7455
US

IV. Provider business mailing address

130 CORRIDOR RD UNIT 3292
PONTE VEDRA BEACH FL
32004-7833
US

V. Phone/Fax

Practice location:
  • Phone: 334-663-1315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: