Provider Demographics
NPI:1750341996
Name:ROLL-MEDEROS, JAN (MSW)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:
Last Name:ROLL-MEDEROS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 FOREST HILLS ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2935
Mailing Address - Country:US
Mailing Address - Phone:617-524-2415
Mailing Address - Fax:617-524-7717
Practice Address - Street 1:86 FOREST HILLS ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2935
Practice Address - Country:US
Practice Address - Phone:617-524-2415
Practice Address - Fax:617-524-7717
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1050531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852094Medicaid
MA1891260Medicaid
MAP04867OtherBLUE CROSS BLUE SHIELD MA
MA110286000OtherMAGELLAN BEHAVIORAL HEALT
MA1019670OtherNEIGHBORHOOD HEALTH PLAN
MAP22420Medicare ID - Type Unspecified