Provider Demographics
NPI:1629410923
Name:ROSHELL, JERRY K
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:K
Last Name:ROSHELL
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 1:6077 FAUNA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-8215
Mailing Address - Country:US
Mailing Address - Phone:414-530-4079
Mailing Address - Fax:
Practice Address - Street 1:6077 FAUNA DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-8215
Practice Address - Country:US
Practice Address - Phone:414-530-4079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-27
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman