Provider Demographics
NPI:1275687931
Name:ROAN, JESSICA ELLEN (DC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:ROAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SANDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1252
Mailing Address - Country:US
Mailing Address - Phone:508-238-9222
Mailing Address - Fax:
Practice Address - Street 1:800 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-2125
Practice Address - Country:US
Practice Address - Phone:508-234-8222
Practice Address - Fax:508-234-7558
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45818Medicare ID - Type Unspecified