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General NPI Number Information
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NPI Number | 1528576493
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Entity Type | Individual
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Provider Name | JACOB ROACH M.S., BCBA
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Gender | Male
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Dates
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Enumeration Date | 01/12/2018
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Last Update Date | 08/13/2025
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Provider Practice Location Address
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Address Line | 710 E FOOTHILL BLVD
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City | UPLAND
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State | CA
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Zip | 91786-4029
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Country | US
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Telephone | 626-567-5678
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Fax |
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Provider Business Mailing Address
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Address Line | 17221 WALNUT AVE
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City | FONTANA
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State | CA
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Zip | 92336-1580
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Country | US
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Telephone | 840-232-2968
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-20-43661
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License Number State | CA
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