Provider Demographics
NPI:1174851455
Name:ROARK, JON BRADLEY (LPC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:BRADLEY
Last Name:ROARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:BRADLEY
Other - Middle Name:
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:6833 82ND ST STE 102
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5070
Mailing Address - Country:US
Mailing Address - Phone:806-438-4510
Mailing Address - Fax:
Practice Address - Street 1:6833 82ND ST STE 102
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5070
Practice Address - Country:US
Practice Address - Phone:806-438-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009000984101Y00000X, 101YP2500X
TX72022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor