MEDICARE: JENNIFER LEE ROSS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.027767	IL

General Provider Information

NPI Number	:	1619798568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LEE ROSS LCSW

Provider Business Mailing Address
First Line	:	1121 E MAIN ST STE 310
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2276
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 E MAIN ST STE 310
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2276
Country	:	US
Telephone Number	:	630-277-9731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	10/23/2024

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