Provider Demographics
NPI:1003175993
Name:ROSE, JENNIFER NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 JEFFERSON ST N
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1380
Mailing Address - Country:US
Mailing Address - Phone:304-645-3220
Mailing Address - Fax:844-479-4545
Practice Address - Street 1:1464 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1380
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:844-479-4545
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2724207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810029042Medicaid
WVWV4911BMedicare PIN