Provider Demographics
NPI:1316122088
Name:JACKSON, ROSE LOUISE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:LOUISE
Last Name:JACKSON
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 1:3450 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3233
Mailing Address - Country:US
Mailing Address - Phone:314-249-9765
Mailing Address - Fax:314-771-5063
Practice Address - Street 1:3450 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3233
Practice Address - Country:US
Practice Address - Phone:314-249-9765
Practice Address - Fax:314-771-5063
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCC0657115251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316122088Medicare NSC