Provider Demographics
NPI:1326575176
Name:ROSE, JACODY
Entity Type:Individual
Prefix:
First Name:JACODY
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7240 CROWDER BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70127-1922
Mailing Address - Country:US
Mailing Address - Phone:504-644-4132
Mailing Address - Fax:
Practice Address - Street 1:7240 CROWDER BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-1922
Practice Address - Country:US
Practice Address - Phone:504-644-4132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health