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General NPI Number Information
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NPI Number | 1619883071
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Entity Type | Individual
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Provider Name | JACOB ROSS BUCKLEY ROACH
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Gender | Male
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Dates
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Enumeration Date | 08/24/2026
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Last Update Date | 08/24/2026
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Provider Practice Location Address
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Address Line | 124 E 108TH ST
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City | NEW YORK
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State | NY
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Zip | 10029-3501
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Country | US
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Telephone | 929-527-2824
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Fax |
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Provider Business Mailing Address
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Address Line | 1968 72ND ST APT 2F
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City | BROOKLYN
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State | NY
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Zip | 11204-5347
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Country | US
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Telephone | 203-997-9867
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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