Provider Demographics
NPI:1295433662
Name:EICHIE, ROSHANDA SHAREE JACKSON
Entity type:Individual
Prefix:
First Name:ROSHANDA
Middle Name:SHAREE JACKSON
Last Name:EICHIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSHANDA
Other - Middle Name:JACKSON
Other - Last Name:EICHIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AMFT
Mailing Address - Street 1:PO BOX 30115
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92413-0115
Mailing Address - Country:US
Mailing Address - Phone:909-659-8632
Mailing Address - Fax:
Practice Address - Street 1:14393 PARK AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392
Practice Address - Country:US
Practice Address - Phone:442-327-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129242103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical