Provider Demographics
NPI:1164828240
Name:ROSS, JENNA M (LSCSW)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:WELLEMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1421 E 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4119
Mailing Address - Country:US
Mailing Address - Phone:316-685-9311
Mailing Address - Fax:316-633-4283
Practice Address - Street 1:400 N WOODLAWN ST STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4331
Practice Address - Country:US
Practice Address - Phone:316-685-9311
Practice Address - Fax:316-633-4283
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS49841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201104250CMedicaid