Provider Demographics
NPI:1396597068
Name:HOWARD, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:HOWARD
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 1:2603 PROSPERITY ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7044
Mailing Address - Country:US
Mailing Address - Phone:601-454-9757
Mailing Address - Fax:
Practice Address - Street 1:220 AVALON CIR STE C
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7670
Practice Address - Country:US
Practice Address - Phone:690-139-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP319998164W00000X
MSLMT2937225700000X
GALMT014437225700000X
172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist