Healthcare Provider Details

I. General information

NPI: 1003589896
Provider Name (Legal Business Name): JENNIFER ROS CRAIG OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7712 OLD CANTON RD
MADISON MS
39110-9299
US

IV. Provider business mailing address

5110 CANTON HEIGHTS DR
JACKSON MS
39211-4515
US

V. Phone/Fax

Practice location:
  • Phone: 601-427-5775
  • Fax: 601-206-0668
Mailing address:
  • Phone: 601-750-4493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT1361
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: