Healthcare Provider Details

I. General information

NPI: 1073280350
Provider Name (Legal Business Name): JESSE ROSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6102 HAMILTON WAY
EASTAMPTON TOWNSHIP NJ
08060-1673
US

IV. Provider business mailing address

310 CEDAR LN
MOUNT LAUREL NJ
08054-2166
US

V. Phone/Fax

Practice location:
  • Phone: 609-284-9129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: