Provider Demographics
NPI:1588475859
Name:ROUSE, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ROUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452604 E 980 RD
Mailing Address - Street 2:
Mailing Address - City:VIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74962-5253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:452604 E 980 RD
Practice Address - Street 2:
Practice Address - City:VIAN
Practice Address - State:OK
Practice Address - Zip Code:74962-5253
Practice Address - Country:US
Practice Address - Phone:918-773-2339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist