Provider Demographics
NPI:1912551375
Name:ROSALES, JACLENE MARIE
Entity Type:Individual
Prefix:
First Name:JACLENE
Middle Name:MARIE
Last Name:ROSALES
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 1:20034 OTOOLE RD SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9046
Mailing Address - Country:US
Mailing Address - Phone:360-894-1493
Mailing Address - Fax:
Practice Address - Street 1:8414 JOHN DOWER RD SW UNIT 12
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2574
Practice Address - Country:US
Practice Address - Phone:419-701-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA212292901OtherDSHS (DEPARTMENT OF SOCIAL & HEALTH SERVICES)