Provider Demographics
NPI:1982833075
Name:ROSE, JESSICA FAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:FAYNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 FANNIN ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-5389
Mailing Address - Country:US
Mailing Address - Phone:832-325-7181
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 1400
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:832-325-7181
Practice Address - Fax:713-512-2200
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6887208200000X
AZ006262208600000X
PAOS0185212086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery