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General NPI Number Information
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NPI Number | 1770355851
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Entity Type | Individual
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Provider Name | JACOB ROSS FNP- C
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Gender | Male
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Dates
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Enumeration Date | 10/23/2023
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 1600 DELTA WATERS RD STE 107
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City | MEDFORD
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State | OR
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Zip | 97504-9114
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Country | US
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Telephone | 541-858-2515
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Fax |
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Provider Business Mailing Address
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Address Line | 815 N CENTRAL AVE STE C
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City | MEDFORD
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State | OR
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Zip | 97501-5873
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Country | US
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Telephone | 541-734-9030
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 10031846
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License Number State | OR
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