Provider Demographics
NPI:1972207553
Name:ROSE, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12665 VILLAGE LN APT 3519
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2853
Mailing Address - Country:US
Mailing Address - Phone:415-686-2327
Mailing Address - Fax:
Practice Address - Street 1:12665 VILLAGE LN APT 3519
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90094-2853
Practice Address - Country:US
Practice Address - Phone:415-686-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137184106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist