Healthcare Provider Details

I. General information

NPI: 1275679300
Provider Name (Legal Business Name): DIANE JONES ROSS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANE JONES

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

131 COVINGTON DR
GRENADA MS
38901-9720
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-6777
  • Fax: 601-605-8869
Mailing address:
  • Phone: 662-226-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3907
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: