Provider Demographics
NPI:1851785489
Name:ROESCH, JAMIE K (RN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:K
Last Name:ROESCH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:K
Other - Last Name:VAN DYKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 W JIMMIE LEEDS RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9406
Mailing Address - Country:US
Mailing Address - Phone:609-652-8316
Mailing Address - Fax:609-653-8764
Practice Address - Street 1:44 E JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9599
Practice Address - Country:US
Practice Address - Phone:609-652-7349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR12667000390200000X
NJ26NJ00599700363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0498891Medicaid
NJ0498891Medicaid
NJ473510ZDDPMedicare PIN
NJ473510ZEKDMedicare PIN