Provider Demographics
NPI:1558812818
Name:ROSE, JORDAN (BCBA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2928
Mailing Address - Country:US
Mailing Address - Phone:508-688-4695
Mailing Address - Fax:617-925-9217
Practice Address - Street 1:101 LONGWATER CIR STE 101
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1641
Practice Address - Country:US
Practice Address - Phone:845-267-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-23502103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst