Provider Demographics
NPI:1760063606
Name:ROSE, JESSICA L (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11351 MAJESTIC ACRES TER
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33473-7807
Mailing Address - Country:US
Mailing Address - Phone:561-213-6960
Mailing Address - Fax:
Practice Address - Street 1:7727 LAKE UNDERHILL RD STE 115
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8224
Practice Address - Country:US
Practice Address - Phone:407-303-6413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program