Healthcare Provider Details

I. General information

NPI: 1639341555
Provider Name (Legal Business Name): JESSICA R ROSS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 S MAIN ST
TRENTON FL
32693-3239
US

IV. Provider business mailing address

3543 SW 30TH WAY #107
GAINESVILLE FL
32608-2751
US

V. Phone/Fax

Practice location:
  • Phone: 352-463-2374
  • Fax: 352-463-2726
Mailing address:
  • Phone: 217-827-6158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 109165
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: