Provider Demographics
NPI:1699892703
Name:ROSS, JACKIE (PT DPT)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT DPT
Mailing Address - Street 1:6738 108TH ST
Mailing Address - Street 2:C51
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2355
Mailing Address - Country:US
Mailing Address - Phone:718-575-2177
Mailing Address - Fax:
Practice Address - Street 1:6738 108TH ST
Practice Address - Street 2:C51
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2355
Practice Address - Country:US
Practice Address - Phone:718-575-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist