Healthcare Provider Details

I. General information

NPI: 1568345817
Provider Name (Legal Business Name): JAIDA ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

PO BOX 735031
CHICAGO IL
60673-5031
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6380
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8705-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: