Provider Demographics
NPI:1093191256
Name:ROSE, JENNIE LOUISE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:LOUISE
Last Name:ROSE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MS
Other - First Name:JENNIE
Other - Middle Name:LOUISE
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:701 S. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-259-5700
Mailing Address - Fax:
Practice Address - Street 1:701 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-259-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4459235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200612430Medicaid