Provider Demographics
NPI:1922383595
Name:ROSE, JACQUELINE E (LMSW)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:E
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 GILMORE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120
Mailing Address - Country:US
Mailing Address - Phone:716-807-3753
Mailing Address - Fax:716-870-3751
Practice Address - Street 1:789 GILMORE AVE
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6743
Practice Address - Country:US
Practice Address - Phone:716-807-3753
Practice Address - Fax:716-870-3751
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0882281041C0700X
NY394871041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01377162Medicaid