Healthcare Provider Details

I. General information

NPI: 1629792221
Provider Name (Legal Business Name): JESSICA LYNN ROSS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5693 YMCA PARK DR W
FORT WAYNE IN
46835-3280
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-469-6603
  • Fax: 260-486-6123
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number28243747A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number71013141A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: