Provider Demographics
NPI:1861028581
Name:ROSE, JESSICA H (RN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:H
Last Name:ROSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 E BLUE ROCK WAY
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-2270
Mailing Address - Country:US
Mailing Address - Phone:813-451-9254
Mailing Address - Fax:
Practice Address - Street 1:584 E BLUE ROCK WAY
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-2270
Practice Address - Country:US
Practice Address - Phone:813-451-9254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ148950163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ148950OtherLICENSE