Provider Demographics
NPI:1548565054
Name:DEROSA, JENNIFER L (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DEROSA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 EDWARDS MILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5243
Mailing Address - Country:US
Mailing Address - Phone:919-863-6856
Mailing Address - Fax:919-863-6821
Practice Address - Street 1:3001 EDWARDS MILL RD # 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5243
Practice Address - Country:US
Practice Address - Phone:197-814-0609
Practice Address - Fax:919-781-5246
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist