Provider Demographics
NPI:1174089965
Name:ROSA, JENNICA LISETTE (NP-C)
Entity type:Individual
Prefix:
First Name:JENNICA
Middle Name:LISETTE
Last Name:ROSA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 TACOMA AVE S APT 303
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-2020
Mailing Address - Country:US
Mailing Address - Phone:210-906-9658
Mailing Address - Fax:
Practice Address - Street 1:5046 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:WA
Practice Address - Zip Code:98407-3118
Practice Address - Country:US
Practice Address - Phone:210-906-9658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140646363LF0000X
WAAP61341503363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily