Provider Demographics
NPI:1265749386
Name:ROUSE, JEANA E
Entity type:Individual
Prefix:MISS
First Name:JEANA
Middle Name:E
Last Name:ROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-2719
Mailing Address - Country:US
Mailing Address - Phone:904-633-2050
Mailing Address - Fax:
Practice Address - Street 1:341 W 18TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-2719
Practice Address - Country:US
Practice Address - Phone:904-633-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029591401Medicaid