Provider Demographics
NPI:1336680081
Name:ROACH, JESSE MARCIAL
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:MARCIAL
Last Name:ROACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3903
Mailing Address - Country:US
Mailing Address - Phone:510-809-1780
Mailing Address - Fax:510-893-1642
Practice Address - Street 1:1422 HARRISON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3903
Practice Address - Country:US
Practice Address - Phone:510-809-1780
Practice Address - Fax:510-893-1642
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator