1073842423 NPI number — MS. JENNIFER ARI ROSE AMFT LPC

Table of content: MS. JENNIFER ARI ROSE AMFT LPC (NPI 1073842423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073842423 NPI number — MS. JENNIFER ARI ROSE AMFT LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSE
Provider First Name:
JENNIFER
Provider Middle Name:
ARI
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AMFT LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUCK
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073842423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 S UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62901-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-351-0743
Provider Business Mailing Address Fax Number:
618-351-0945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 S UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-2925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-351-0743
Provider Business Practice Location Address Fax Number:
618-351-0945
Provider Enumeration Date:
12/14/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  178.005844 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)