Basic Information
| Provider Information | |||||||||
| NPI: | 1821457185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROSE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | LAMOREAU | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199992010 | ||||||||
| FaxNumber: | 4199996284 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199992010 | ||||||||
| FaxNumber: | 4199996284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 015437 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT015437 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.