Healthcare Provider Details

I. General information

NPI: 1083036768
Provider Name (Legal Business Name): JEANNE ROSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 MONTAGUE RD
SHUTESBURY MA
01072-9709
US

IV. Provider business mailing address

49 MONTAGUE RD
SHUTESBURY MA
01072-9709
US

V. Phone/Fax

Practice location:
  • Phone: 413-259-1814
  • Fax:
Mailing address:
  • Phone: 413-259-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4955
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: