Provider Demographics
NPI:1578118048
Name:ROSS, JACQUELINE DENISE (CRNP)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:ROSS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 11087
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-0087
Mailing Address - Country:US
Mailing Address - Phone:334-481-1599
Mailing Address - Fax:334-356-1426
Practice Address - Street 1:108 N PARK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1645
Practice Address - Country:US
Practice Address - Phone:770-487-7807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN323435363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care