Provider Demographics
NPI:1326401183
Name:ROACH, JENNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 TYBEE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4171
Mailing Address - Country:US
Mailing Address - Phone:337-433-7272
Mailing Address - Fax:337-433-0730
Practice Address - Street 1:2000 TYBEE LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4171
Practice Address - Country:US
Practice Address - Phone:337-433-7272
Practice Address - Fax:337-433-0730
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA321797207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA321797OtherSTATE MEDICAL LICENSE