Provider Demographics
NPI:1073842423
Name:ROSE, JENNIFER ARI (AMFT LPC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ARI
Last Name:ROSE
Suffix:
Gender:F
Credentials:AMFT LPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:214 S UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2925
Mailing Address - Country:US
Mailing Address - Phone:618-351-0743
Mailing Address - Fax:618-351-0945
Practice Address - Street 1:214 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2925
Practice Address - Country:US
Practice Address - Phone:618-351-0743
Practice Address - Fax:618-351-0945
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.005844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional