Provider Demographics
NPI:1871341826
Name:ROSE, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:ROSE
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:PO BOX 1404
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1809 CLARENDON AVE
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-5843
Practice Address - Country:US
Practice Address - Phone:205-253-7891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-23
Deactivation Date:2024-05-09
Deactivation Code:
Reactivation Date:2024-05-23
Provider Licenses
StateLicense IDTaxonomies
MO2022044538225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation