Healthcare Provider Details

I. General information

NPI: 1043419211
Provider Name (Legal Business Name): JILL ROSE BSHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 E COLORADO BLVD STE 100
PASADENA CA
91107-6622
US

IV. Provider business mailing address

427 MARYGROVE RD
CLAREMONT CA
91711-5135
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax: 626-577-2543
Mailing address:
  • Phone: 909-525-7411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: