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General NPI Number Information
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NPI Number | 1578118048
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Entity Type | Individual
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Provider Name | JACQUELINE DENISE ROSS CRNP
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Gender | Female
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Dates
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Enumeration Date | 08/01/2019
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Last Update Date | 02/13/2025
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Provider Practice Location Address
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Address Line | 108 N PARK DR
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1645
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Country | US
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Telephone | 770-487-7807
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11087
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City | MONTGOMERY
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State | AL
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Zip | 36111-0087
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Country | US
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Telephone | 334-481-1599
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Fax | 334-356-1426
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | RN323435
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License Number State | GA
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