Provider Demographics
NPI:1134671043
Name:ROSE, JACOB (MS,SLP-CFY)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MS,SLP-CFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22464 PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:ONAWA
Mailing Address - State:IA
Mailing Address - Zip Code:51040-8528
Mailing Address - Country:US
Mailing Address - Phone:859-979-2618
Mailing Address - Fax:
Practice Address - Street 1:2524 GLENN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-2768
Practice Address - Country:US
Practice Address - Phone:712-226-2253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084584235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist