Provider Demographics
NPI:1366807786
Name:ROSE, JENNA COLEMAN
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:COLEMAN
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 276
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-0276
Mailing Address - Country:US
Mailing Address - Phone:276-701-5696
Mailing Address - Fax:
Practice Address - Street 1:2114 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2858
Practice Address - Country:US
Practice Address - Phone:423-928-6464
Practice Address - Fax:423-232-7970
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006998235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist