Provider Demographics
NPI:1922889591
Name:ROSE, JODI ALICIA (MS LAC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ALICIA
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 ADAMS ST APT 8F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2871
Mailing Address - Country:US
Mailing Address - Phone:917-348-3005
Mailing Address - Fax:
Practice Address - Street 1:333 E 46TH ST APT 1J
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-7426
Practice Address - Country:US
Practice Address - Phone:917-348-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002775171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist