Provider Demographics
NPI:1518149418
Name:ROSE, JENNIFER ROBIN (LMSW, LMAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ROBIN
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMSW, LMAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:HALSTEAD
Mailing Address - State:KS
Mailing Address - Zip Code:67056-2304
Mailing Address - Country:US
Mailing Address - Phone:316-217-2994
Mailing Address - Fax:
Practice Address - Street 1:820 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3605
Practice Address - Country:US
Practice Address - Phone:162-027-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS101YA0400X
KS01078101YA0400X
KS9354104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)