MEDICARE: JESSICA RYAN-GRAVES ROTHWELL

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	101YP2500X	Professional Counselor	18119	CA
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1467238840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RYAN-GRAVES ROTHWELL

Provider Business Mailing Address
First Line	:	PO BOX 32392
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95152-2392
Country	:	US
Telephone Number	:	214-326-9633
Fax Number	:

Provider Business Practice Location Address
First Line	:	2087 LIMEWOOD DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95132-1234
Country	:	US
Telephone Number	:	214-326-9633
Fax Number	:

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

Provider Enumeration Date	:	09/01/2023
Last Update Date	:	01/22/2025

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