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General NPI Number Information
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NPI Number | 1164095964
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Entity Type | Individual
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Provider Name | JORDAN ROSE
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Gender | Male
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Dates
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Enumeration Date | 07/20/2021
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Last Update Date | 06/26/2024
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Provider Practice Location Address
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Address Line | 1287 FULTON RD
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City | SANTA ROSA
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State | CA
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Zip | 95401-4923
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Country | US
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Telephone | 707-800-7700
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 464
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City | MILL VALLEY
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State | CA
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Zip | 94942-0464
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Country | US
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Telephone | 707-800-7700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 95224646
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95025794
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License Number State | CA
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