Provider Demographics
NPI:1710228374
Name:RODERICK, JESSE RYAN (BA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:RYAN
Last Name:RODERICK
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 1/2 S VISTA BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3423
Mailing Address - Country:US
Mailing Address - Phone:626-806-2306
Mailing Address - Fax:
Practice Address - Street 1:255 E SANTA CLARA ST STE 210
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-7233
Practice Address - Country:US
Practice Address - Phone:626-824-0982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst