Provider Demographics
NPI:1487930368
Name:ROSS, JAYCOB MICHEL (DPT)
Entity type:Individual
Prefix:
First Name:JAYCOB
Middle Name:MICHEL
Last Name:ROSS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6100
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6100
Mailing Address - Country:US
Mailing Address - Phone:505-424-0131
Mailing Address - Fax:505-424-1299
Practice Address - Street 1:2954 RODEO PARK DR W
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6351
Practice Address - Country:US
Practice Address - Phone:505-424-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4013225100000X
MN8850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist