Provider Demographics
NPI:1689966350
Name:DEROSIA, JENNIFER SUE (LPN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:DEROSIA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:403 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-2042
Practice Address - Country:US
Practice Address - Phone:855-608-3560
Practice Address - Fax:618-956-9349
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043077866164W00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No164W00000XNursing Service ProvidersLicensed Practical Nurse