Provider Demographics
NPI:1649553959
Name:ROSENTHAL, JAMIE ROSE (PA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:ROSE
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 HIGHLAND RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1682
Mailing Address - Country:US
Mailing Address - Phone:248-666-9332
Mailing Address - Fax:248-666-0340
Practice Address - Street 1:6620 HIGHLAND RD STE 101
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1682
Practice Address - Country:US
Practice Address - Phone:248-666-9332
Practice Address - Fax:248-666-0340
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006188363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical