Healthcare Provider Details

I. General information

NPI: 1124755715
Provider Name (Legal Business Name): JOHNATHAN SHANE ROACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 CADDO ST STE 6
ARKADELPHIA AR
71923-5307
US

IV. Provider business mailing address

10311 W MARKHAM ST
LITTLE ROCK AR
72205-2135
US

V. Phone/Fax

Practice location:
  • Phone: 870-230-8217
  • Fax:
Mailing address:
  • Phone: 870-340-2636
  • Fax: 888-816-7916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number91413
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2507012
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: