Provider Demographics
NPI:1649490095
Name:ROSE, JILL CHRISTIN (PT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:CHRISTIN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5285 PALM ISLES BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3955
Mailing Address - Country:US
Mailing Address - Phone:773-726-2401
Mailing Address - Fax:
Practice Address - Street 1:11505 PALMBRUSH TRL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-2917
Practice Address - Country:US
Practice Address - Phone:941-747-2090
Practice Address - Fax:941-487-6233
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22420225100000X
MD21535225100000X
NY5529209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0A2GOtherBCBS
FLY0A2GOtherBCBS