Healthcare Provider Details

I. General information

NPI: 1518305028
Provider Name (Legal Business Name): MS. JACQUELINE S ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 CENTRE ST STE 824
NEW YORK NY
10013-4558
US

IV. Provider business mailing address

134 N 4TH ST
BROOKLYN NY
11249-3296
US

V. Phone/Fax

Practice location:
  • Phone: 646-450-7748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0135201
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05767100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number092563
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61541452
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number086545
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: