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General NPI Number Information
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NPI Number | 1437388295
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Entity Type | Individual
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Provider Name | JESSICA LYNN ROACH DPT
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Gender | Female
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Dates
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Enumeration Date | 07/14/2009
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Last Update Date | 12/11/2020
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Provider Practice Location Address
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Address Line | 4301 MACCORKLE AVE SE
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City | CHARLESTON
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State | WV
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Zip | 25304-2503
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Country | US
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Telephone | 304-720-9185
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Fax |
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Provider Business Mailing Address
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Address Line | 1106 IVYWOOD LN
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City | SOUTH CHARLESTON
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State | WV
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Zip | 25309-1708
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Country | US
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Telephone | 304-549-8273
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2764
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License Number State | WV
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