Provider Demographics
NPI:1326213059
Name:ROACH, JENNIE L (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:L
Last Name:ROACH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 REID DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-2724
Mailing Address - Country:US
Mailing Address - Phone:252-338-0137
Mailing Address - Fax:252-338-4512
Practice Address - Street 1:901 HALSTEAD BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6920
Practice Address - Country:US
Practice Address - Phone:252-338-0137
Practice Address - Fax:252-338-4512
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1704225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist