Provider Demographics
NPI:1366846628
Name:ROSE, JENNIFER PATRICIA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:ROSE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 SE 282ND CT
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-9541
Mailing Address - Country:US
Mailing Address - Phone:360-818-4495
Mailing Address - Fax:
Practice Address - Street 1:2903 SE 282ND CT
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-9541
Practice Address - Country:US
Practice Address - Phone:360-818-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW600401291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical