Provider Demographics
NPI:1114042801
Name:ROSELLO, JACQUELINE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:ROSELLO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 LASALLE DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAWN
Mailing Address - State:PA
Mailing Address - Zip Code:19609-1216
Mailing Address - Country:US
Mailing Address - Phone:610-670-9511
Mailing Address - Fax:
Practice Address - Street 1:1011 BERKS ROAD
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533
Practice Address - Country:US
Practice Address - Phone:610-376-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP000212L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant