Provider Demographics
NPI:1215563572
Name:ROSS, JENNIFER FULLER (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FULLER
Last Name:ROSS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3481 SIX MILE HWY
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:SC
Mailing Address - Zip Code:29630-9526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3481 SIX MILE HWY
Practice Address - Street 2:
Practice Address - City:CENTRAL
Practice Address - State:SC
Practice Address - Zip Code:29630-9526
Practice Address - Country:US
Practice Address - Phone:864-616-7260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225593163WC0200X
SC131272367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine