Provider Demographics
NPI:1699037705
Name:JACKSON, ROSE DENISE
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:DENISE
Last Name:JACKSON
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 1:11565 LONE DESERT DR
Mailing Address - Street 2:11565 LONE DESERT DR
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-5566
Mailing Address - Country:US
Mailing Address - Phone:775-224-0136
Mailing Address - Fax:
Practice Address - Street 1:11565 LONE DESERT DR
Practice Address - Street 2:11565 LONE DESERT DR
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-5566
Practice Address - Country:US
Practice Address - Phone:775-224-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator