=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982905659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANN ROSEN MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2010
-----------------------------------------------------
Last Update Date | 01/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3384 WOODS EDGE CIR STE 104
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-249-5292
-----------------------------------------------------
Fax | 239-244-3342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16217 CAMDEN LAKES CIR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34110-2882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-450-7144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA12231
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------