Provider Demographics
NPI:1104864255
Name:ROSE, JENNIFER BETH (LISW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BETH
Last Name:ROSE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 GOLF COURSE RD SE STE D
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1634
Mailing Address - Country:US
Mailing Address - Phone:505-639-1312
Mailing Address - Fax:
Practice Address - Street 1:2111 GOLF COURSE RD SE STE D
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1634
Practice Address - Country:US
Practice Address - Phone:505-639-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-069991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02351714Medicaid
NM1598218190OtherNPI TYPE 2
NM1104864255OtherNPI TYPE
NM17301866Medicaid