Healthcare Provider Details

I. General information

NPI: 1356822266
Provider Name (Legal Business Name): JARED ALDON ROGGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 ALHAMBRA BLVD STE 200
SACRAMENTO CA
95816-6510
US

IV. Provider business mailing address

1300 ETHAN WAY STE 600
SACRAMENTO CA
95825-2296
US

V. Phone/Fax

Practice location:
  • Phone: 916-679-3590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number4704248546
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95030005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: