Provider Demographics
NPI:1316130750
Name:ROSE, JENNIFER MARGARET (RN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARGARET
Last Name:ROSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 PINYON PINE LN
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-4163
Mailing Address - Country:US
Mailing Address - Phone:209-549-1938
Mailing Address - Fax:209-549-1938
Practice Address - Street 1:1128 MARSH WREN DR
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:CA
Practice Address - Zip Code:95363-9053
Practice Address - Country:US
Practice Address - Phone:209-892-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA599810163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN005020Medicaid
CAEPS016900Medicaid