Provider Demographics
NPI:1316558166
Name:ROSE, JACQUELINE DENISE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENISE
Last Name:ROSE
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 1:512 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-1914
Mailing Address - Country:US
Mailing Address - Phone:304-356-6572
Mailing Address - Fax:
Practice Address - Street 1:512 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-1914
Practice Address - Country:US
Practice Address - Phone:304-356-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant