Provider Demographics
NPI:1861588923
Name:ROSS, JENNIFER K (BCHIS)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:K
Last Name:ROSS
Suffix:
Gender:F
Credentials:BCHIS
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:KAMAHELE
Other - Last Name:ROSS-LANDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:600 HARMON LOOP RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-6536
Mailing Address - Country:US
Mailing Address - Phone:671-637-4327
Mailing Address - Fax:671-637-7018
Practice Address - Street 1:600 HARMON LOOP RD
Practice Address - Street 2:SUITE 106
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6536
Practice Address - Country:US
Practice Address - Phone:671-637-4327
Practice Address - Fax:671-637-7018
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA 60221924237700000X
GU30-201100718-001237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU164Medicaid
2R027OtherMEDICAID SAIPAN