Provider Demographics
NPI:1144379645
Name:DE LA ROSA, JENNY HARRISON (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:HARRISON
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 LILAC CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2633
Mailing Address - Country:US
Mailing Address - Phone:512-619-5953
Mailing Address - Fax:
Practice Address - Street 1:6207 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-1060
Practice Address - Country:US
Practice Address - Phone:512-454-3743
Practice Address - Fax:512-334-4465
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1167360225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1144479645Medicaid
TX1144379645Medicaid