Provider Demographics
NPI:1043228299
Name:DEROSA, JENNIFER J
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:DEROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BROADWAY E
Mailing Address - Street 2:BOX 20481
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5793
Mailing Address - Country:US
Mailing Address - Phone:206-403-0190
Mailing Address - Fax:
Practice Address - Street 1:526 YALE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5542
Practice Address - Country:US
Practice Address - Phone:206-403-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00004111225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist