Healthcare Provider Details

I. General information

NPI: 1356160592
Provider Name (Legal Business Name): JAIME ANTONIO ROQUE RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8914 OPPER LN
HOUSTON TX
77064-3468
US

IV. Provider business mailing address

8914 OPPER LN
HOUSTON TX
77064-3468
US

V. Phone/Fax

Practice location:
  • Phone: 346-366-0071
  • Fax:
Mailing address:
  • Phone: 346-366-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number24-340258
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: