Healthcare Provider Details

I. General information

NPI: 1174735872
Provider Name (Legal Business Name): JENICA M ROSE-STINE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 EL CHICO TRL STE 102
WILLOW PARK TX
76087-8864
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 817-441-5412
  • Fax: 817-441-9354
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM8294
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: