Provider Demographics
NPI:1356080402
Name:ROSENAUER, JERRICA LOUISE (CLC)
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:LOUISE
Last Name:ROSENAUER
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24776 CLEMENTINE OUTER RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:MO
Mailing Address - Zip Code:65550-9048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24776 CLEMENTINE OUTER RD
Practice Address - Street 2:
Practice Address - City:NEWBURG
Practice Address - State:MO
Practice Address - Zip Code:65550-9048
Practice Address - Country:US
Practice Address - Phone:573-528-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO344650174N00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN