Provider Demographics
NPI:1609211242
Name:ROSE, JENNIFER ANN (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 COUNTY HIGHWAY 138 STE 203
Mailing Address - Street 2:
Mailing Address - City:BROADALBIN
Mailing Address - State:NY
Mailing Address - Zip Code:12025-6902
Mailing Address - Country:US
Mailing Address - Phone:518-883-1023
Mailing Address - Fax:518-883-1293
Practice Address - Street 1:103 COUNTY HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:BROADALBIN
Practice Address - State:NY
Practice Address - Zip Code:12025-6902
Practice Address - Country:US
Practice Address - Phone:518-883-1023
Practice Address - Fax:518-583-7665
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382401363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03648780Medicaid
NYJ400096461Medicare PIN