Basic Information
| Provider Information | |||||||||
| NPI: | 1003247677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19529 34TH DR SE | ||||||||
| Address2: | |||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980127984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064277809 | ||||||||
| FaxNumber: | 4252585275 | ||||||||
| Practice Location | |||||||||
| Address1: | 19529 34TH DR SE | ||||||||
| Address2: | |||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980127984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064277809 | ||||||||
| FaxNumber: | 4252585275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2013 | ||||||||
| LastUpdateDate: | 07/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60335346 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2064277754 | 01 | CONTACT | OTHER |