Provider Demographics
NPI:1326253352
Name:ROSEN, JEROME GEORGE (MED)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:GEORGE
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-3571
Mailing Address - Country:US
Mailing Address - Phone:360-678-0804
Mailing Address - Fax:
Practice Address - Street 1:303 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-3571
Practice Address - Country:US
Practice Address - Phone:360-678-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001406106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist