Provider Demographics
NPI:1003837675
Name:ROSE, JACK C
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:ROSE
Suffix:
Gender:M
Credentials:
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 254947
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-4947
Mailing Address - Country:US
Mailing Address - Phone:916-854-6975
Mailing Address - Fax:916-854-6844
Practice Address - Street 1:2100 WEBSTER ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2373
Practice Address - Country:US
Practice Address - Phone:415-600-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA881522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology