Provider Demographics
NPI:1790385193
Name:ROUSE, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ROUSE
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 1:638 CUTLIP RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9451
Mailing Address - Country:US
Mailing Address - Phone:740-710-2681
Mailing Address - Fax:
Practice Address - Street 1:640 CUTLIP RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9451
Practice Address - Country:US
Practice Address - Phone:740-710-2681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4064686OtherOHIO DODD
OH0164124Medicaid