Provider Demographics
NPI:1063708188
Name:ROSS, JAE LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:LEE
Last Name:ROSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6706
Mailing Address - Country:US
Mailing Address - Phone:646-227-3764
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00701400103TC0700X
TX37386103TC0700X
NY025249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical