MEDICARE: JACOB ROSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	137184	CA

General Provider Information

NPI Number	:	1972207553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ROSE

Provider Business Mailing Address
First Line	:	12665 VILLAGE LN APT 3519
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90094-2853
Country	:	US
Telephone Number	:	415-686-2327
Fax Number	:

Provider Business Practice Location Address
First Line	:	12665 VILLAGE LN APT 3519
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90094-2853
Country	:	US
Telephone Number	:	415-686-2327
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2023
Last Update Date	:	03/28/2023

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Directions to “ JACOB ROSE ” Practice Location

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