Provider Demographics
NPI:1942797279
Name:ROACH, JENNIS
Entity Type:Individual
Prefix:
First Name:JENNIS
Middle Name:
Last Name:ROACH
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 1:2813 E 116TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2196
Mailing Address - Country:US
Mailing Address - Phone:216-283-4400
Mailing Address - Fax:216-283-5359
Practice Address - Street 1:13422 KINSMAN RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-4410
Practice Address - Country:US
Practice Address - Phone:216-283-4400
Practice Address - Fax:216-283-5359
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator