Provider Demographics
NPI:1497348254
Name:ROSE, JENNIFER R (CNM)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:ROSE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2331
Mailing Address - Country:US
Mailing Address - Phone:307-620-2912
Mailing Address - Fax:
Practice Address - Street 1:1428 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2331
Practice Address - Country:US
Practice Address - Phone:307-620-2912
Practice Address - Fax:307-464-7057
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY46645176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty