Healthcare Provider Details

I. General information

NPI: 1063140986
Provider Name (Legal Business Name): JESSICA ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 W WINCHESTER RD
LIBERTYVILLE IL
60048-5351
US

IV. Provider business mailing address

970 E OAK ST
LAKE IN THE HILLS IL
60156-6169
US

V. Phone/Fax

Practice location:
  • Phone: 847-573-9486
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: