Provider Demographics
NPI:1578860193
Name:ROARK, JEREMY B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:B
Last Name:ROARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 SHUMAC LN SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9355
Mailing Address - Country:US
Mailing Address - Phone:805-570-7688
Mailing Address - Fax:
Practice Address - Street 1:2650 SHUMAC LN SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9355
Practice Address - Country:US
Practice Address - Phone:805-570-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24012103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist