Healthcare Provider Details

I. General information

NPI: 1891474904
Provider Name (Legal Business Name): JANE ROSIE JOSEPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4418
US

IV. Provider business mailing address

2409 VAN LAYDEN WAY
MODESTO CA
95356-2455
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-1211
  • Fax:
Mailing address:
  • Phone: 209-484-2516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95025968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: