Provider Demographics
NPI:1265661805
Name:ROSE, JABRIEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:JABRIEL
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 W JACKSON BLVD
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD
Practice Address - Street 2:SUITE 1111
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3606
Practice Address - Country:US
Practice Address - Phone:847-224-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007542103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical