Provider Demographics
NPI:1689902124
Name:ROSE, JESSICA LYN
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYN
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1564 CORTE REINA CMN
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-7432
Mailing Address - Country:US
Mailing Address - Phone:925-413-0867
Mailing Address - Fax:
Practice Address - Street 1:1564 CORTE REINA CMN
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-7432
Practice Address - Country:US
Practice Address - Phone:925-413-0867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA237521164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse