Healthcare Provider Details

I. General information

NPI: 1235590340
Provider Name (Legal Business Name): JESSICA KATHLEEN ROUSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 09/28/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100
APO AE
09180-3100
US

IV. Provider business mailing address

LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100
APO AE
09180-3100
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-5762
  • Fax:
Mailing address:
  • Phone: 314-590-5762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30359
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number165800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: