Healthcare Provider Details

I. General information

NPI: 1124754809
Provider Name (Legal Business Name): JUSTICE ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 PACIFIC AVE
STOCKTON CA
95211-0110
US

IV. Provider business mailing address

3601 PACIFIC AVE
STOCKTON CA
95211-0110
US

V. Phone/Fax

Practice location:
  • Phone: 209-476-1959
  • Fax:
Mailing address:
  • Phone: 916-364-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: