Provider Demographics
NPI:1386297471
Name:ROSS, JENNIFER (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6640
Mailing Address - Country:US
Mailing Address - Phone:229-226-0741
Mailing Address - Fax:229-227-9360
Practice Address - Street 1:200 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6640
Practice Address - Country:US
Practice Address - Phone:229-226-0741
Practice Address - Fax:229-227-9360
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004295103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist