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General NPI Number Information
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NPI Number | 1992368104
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Entity Type | Individual
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Provider Name | JACKSON ROACH
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Gender | Male
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Dates
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Enumeration Date | 04/15/2019
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Last Update Date | 04/15/2019
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Provider Practice Location Address
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Address Line | 452 S 1ST ST
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City | SAN JOSE
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State | CA
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Zip | 95113-2815
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Country | US
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Telephone | 408-841-4319
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Fax | 408-286-3855
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Provider Business Mailing Address
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Address Line | PO BOX 127
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City | NAPA
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State | CA
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Zip | 94559-0127
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Country | US
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Telephone | 707-255-3300
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Fax | 707-255-3527
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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