Provider Demographics
NPI:1669022554
Name:JAMESON, ROSETTA (RPH)
Entity Type:Individual
Prefix:
First Name:ROSETTA
Middle Name:
Last Name:JAMESON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:ROSIE
Other - Middle Name:
Other - Last Name:JAMESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1313 S UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5943
Mailing Address - Country:US
Mailing Address - Phone:801-373-5665
Mailing Address - Fax:801-373-5986
Practice Address - Street 1:1313 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5943
Practice Address - Country:US
Practice Address - Phone:801-373-5665
Practice Address - Fax:801-373-5986
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT132826-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT132826-1701Medicaid