MEDICARE: JONATHAN D ROOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	BCBA # 1-10-6879	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BCBA # 1-10-6879	OTHER	CA	BCBA CERTIFICATE

General Provider Information

NPI Number	:	1154687564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN D ROOS

Provider Business Mailing Address
First Line	:	8936 S SEPULVEDA BLVD # 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3628
Country	:	US
Telephone Number	:	310-287-0382
Fax Number	:	310-861-5014

Provider Business Practice Location Address
First Line	:	8936 S SEPULVEDA BLVD # 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3628
Country	:	US
Telephone Number	:	310-287-0382
Fax Number	:	310-861-5014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	09/12/2012

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Directions to “ JONATHAN D ROOS ” Practice Location

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