Provider Demographics
NPI:1740339803
Name:ROSE, JACQUELINE ANN (PHD, LPCC-SUPV)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD, LPCC-SUPV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CLARK DR APT F47
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1491
Mailing Address - Country:US
Mailing Address - Phone:614-595-7633
Mailing Address - Fax:
Practice Address - Street 1:10921 REED HARTMAN HWY STE 133
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-2851
Practice Address - Country:US
Practice Address - Phone:513-984-9838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0002439SUPV101YP2500X
OHE0002439101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator