Provider Demographics
NPI:1578682431
Name:ROSE, JENNIFER (MSOM, LAC, LPN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSOM, LAC, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 SHELLEY DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2141
Mailing Address - Country:US
Mailing Address - Phone:262-331-4083
Mailing Address - Fax:
Practice Address - Street 1:4103 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-2509
Practice Address - Country:US
Practice Address - Phone:262-331-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 174400000X
MI4703039858164W00000X
WI423-055171100000X
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Not Answered164W00000XNursing Service ProvidersLicensed Practical Nurse
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered174400000XOther Service ProvidersSpecialist