=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255576351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENEAN E ROSE OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2008
-----------------------------------------------------
Last Update Date | 12/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 SAINT JOHN PL
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-841-6236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 SAINT JOHN PL
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 9629-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------