Provider Demographics
NPI:1598587784
Name:ROSE, JODETTE E (LMSW)
Entity type:Individual
Prefix:
First Name:JODETTE
Middle Name:E
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-0115
Mailing Address - Country:US
Mailing Address - Phone:269-635-2157
Mailing Address - Fax:
Practice Address - Street 1:105 PEARL ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1280
Practice Address - Country:US
Practice Address - Phone:269-635-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011188981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical