Provider Demographics
NPI:1821457185
Name:DEROSE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LAMOREAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3583
Mailing Address - Country:US
Mailing Address - Phone:419-999-2010
Mailing Address - Fax:419-999-6284
Practice Address - Street 1:1100 SHAWNEE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-3529
Practice Address - Country:US
Practice Address - Phone:419-999-2010
Practice Address - Fax:419-999-6284
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH015437225100000X
OHPT015437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist