1104902881 NPI number — MRS. JESSICA BETH ROSENBERG PNP

Table of content: MRS. JESSICA BETH ROSENBERG PNP (NPI 1104902881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104902881 NPI number — MRS. JESSICA BETH ROSENBERG PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSENBERG
Provider First Name:
JESSICA
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104902881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1333 WOODLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN CARLOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-654-6928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
595 PRICE AVE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-369-4147
Provider Business Practice Location Address Fax Number:
650-369-0813
Provider Enumeration Date:
10/27/2006

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: 363LP0200X , with the licence number:  15900 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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