Provider Demographics
NPI:1003940297
Name:ROSS, JACQUELINE J (PTA)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:J
Last Name:ROSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-0686
Mailing Address - Country:US
Mailing Address - Phone:304-298-3602
Mailing Address - Fax:
Practice Address - Street 1:1 DIANE DR
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719-0686
Practice Address - Country:US
Practice Address - Phone:304-298-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0991225200000X
MDA2724225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA2724OtherPHYSICAL THERAPIST ASSIT
WV0991OtherPHYSICAL THERAPIST ASSIST