Provider Demographics
NPI:1952641490
Name:ROMAN, JORGE LUIS (MS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:ROMAN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10372
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-0372
Mailing Address - Country:US
Mailing Address - Phone:865-584-4005
Mailing Address - Fax:865-584-5551
Practice Address - Street 1:813 S NORTHSHORE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-7594
Practice Address - Country:US
Practice Address - Phone:865-584-4005
Practice Address - Fax:865-584-5551
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health