Provider Demographics
NPI:1215757943
Name:LAROSA, JENNIFER LYNN NOEL
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN NOEL
Last Name:LAROSA
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 1:4097 ROCHDALE DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-1131
Mailing Address - Country:US
Mailing Address - Phone:586-215-0029
Mailing Address - Fax:
Practice Address - Street 1:13137 N CLIO RD # G
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-1028
Practice Address - Country:US
Practice Address - Phone:810-686-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005738225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant