Provider Demographics
NPI:1497331649
Name:ROEBUCK, JENNIFER LIN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LIN
Last Name:ROEBUCK
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 1:3301 MICHELSON DR APT 3321
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-4321
Mailing Address - Country:US
Mailing Address - Phone:714-292-2322
Mailing Address - Fax:
Practice Address - Street 1:940 S COAST DR STE 260
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7719
Practice Address - Country:US
Practice Address - Phone:949-524-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125655106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist