Provider Demographics
NPI:1043230766
Name:ROOSA, JENNIFER B (OTR L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:ROOSA
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EDDY STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905
Mailing Address - Country:US
Mailing Address - Phone:401-533-9100
Mailing Address - Fax:
Practice Address - Street 1:1000 EDDY STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
RIOT01061225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISB870OtherBCRI
RIES01788Medicaid
RI0614OtherNHPRI
RI412296OtherEI BLUE CHIP
RI292177OtherEI BLUE CROSS