Healthcare Provider Details

I. General information

NPI: 1760063606
Provider Name (Legal Business Name): JESSICA L ROSE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 05/16/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 LAKE UNDERHILL RD STE 115
ORLANDO FL
32822-8224
US

IV. Provider business mailing address

11351 MAJESTIC ACRES TER
BOYNTON BEACH FL
33473-7807
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6413
  • Fax:
Mailing address:
  • Phone: 561-213-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS20087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: