Healthcare Provider Details

I. General information

NPI: 1871135202
Provider Name (Legal Business Name): JENNIFER I ROSS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 08/02/2024
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 E MAIN STREET
CECILIA KY
42724-7614
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 844-435-0900
  • Fax: 270-858-4029
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number271867
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: