Healthcare Provider Details

I. General information

NPI: 1801150958
Provider Name (Legal Business Name): JERRICK W ROSE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216
US

IV. Provider business mailing address

603 SOUTHERN OAKS DR
FLORENCE MS
39073-9456
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6100
  • Fax: 601-815-5837
Mailing address:
  • Phone: 601-941-6237
  • Fax: 601-815-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3662-12
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3662-12
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberPEDO-482-14
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: