Provider Demographics
NPI:1871955716
Name:ROSE, JACQUELINE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 SAWYER LN
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-5216
Mailing Address - Country:US
Mailing Address - Phone:845-744-8079
Mailing Address - Fax:
Practice Address - Street 1:89 BONIFACE DR
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-7011
Practice Address - Country:US
Practice Address - Phone:845-744-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003350171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist