1376567297 NPI number — MRS. JEANNETTE D ROSS LCSW

Table of content: MRS. JEANNETTE D ROSS LCSW (NPI 1376567297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376567297 NPI number — MRS. JEANNETTE D ROSS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
JEANNETTE
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSS
Provider Other First Name:
JEAN
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376567297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 HUDSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34223-6424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-223-0105
Provider Business Mailing Address Fax Number:
941-681-2663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1460 S MCCALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34223-4864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-223-0105
Provider Business Practice Location Address Fax Number:
941-681-2663
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW0002147 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z2818A . This is a "PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Z2818 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1105340 . This is a "CIGNA BEHAV HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 689672396 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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