MEDICARE: ROSE LOUISE JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	CC0657115	MO

General Provider Information

NPI Number	:	1316122088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE LOUISE JACKSON

Provider Business Mailing Address
First Line	:	3450 INDIANA AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-3233
Country	:	US
Telephone Number	:	314-249-9765
Fax Number	:	314-771-5063

Provider Business Practice Location Address
First Line	:	3450 INDIANA AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-3233
Country	:	US
Telephone Number	:	314-249-9765
Fax Number	:	314-771-5063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2007
Last Update Date	:	01/09/2008

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