Healthcare Provider Details

I. General information

NPI: 1578118048
Provider Name (Legal Business Name): JACQUELINE DENISE ROSS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE R JOHNSON CRNP

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N PARK DR
FAYETTEVILLE GA
30214-1645
US

IV. Provider business mailing address

PO BOX 11087
MONTGOMERY AL
36111-0087
US

V. Phone/Fax

Practice location:
  • Phone: 770-487-7807
  • Fax:
Mailing address:
  • Phone: 334-481-1599
  • Fax: 334-356-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN323435
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: