Provider Demographics
NPI:1306240403
Name:ROACH, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12727 BANKS RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:NC
Mailing Address - Zip Code:28124-9762
Mailing Address - Country:US
Mailing Address - Phone:704-268-9058
Mailing Address - Fax:
Practice Address - Street 1:16905 NORTHCROSS DR STE 170
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5013
Practice Address - Country:US
Practice Address - Phone:704-268-9058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11050101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional