Healthcare Provider Details

I. General information

NPI: 1669693289
Provider Name (Legal Business Name): JIM ROGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26734 JORDAN RD. SUITE A-4
HELENDALE CA
92342-1484
US

IV. Provider business mailing address

P.O. BOX 1484
HELENDALE CA
92342-1484
US

V. Phone/Fax

Practice location:
  • Phone: 760-961-6118
  • Fax: 760-955-2242
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT35622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: