Provider Demographics
NPI:1003247677
Name:ROACH, JENNIFER (MA, LCMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 S 850 W APT 306
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-4654
Mailing Address - Country:US
Mailing Address - Phone:206-427-7754
Mailing Address - Fax:
Practice Address - Street 1:342 S 850 W APT 306
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-4654
Practice Address - Country:US
Practice Address - Phone:206-427-7754
Practice Address - Fax:425-258-5275
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61155476101YM0800X
UT12888612-6004101YM0800X
IDLCPC-8331101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064277754OtherCONTACT