Provider Demographics
NPI:1124880109
Name:ROACH, JESSICA M (LPN, MPH)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:ROACH
Suffix:
Gender:F
Credentials:LPN, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 ETNA RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2532
Mailing Address - Country:US
Mailing Address - Phone:614-440-4362
Mailing Address - Fax:
Practice Address - Street 1:5120 ETNA RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2532
Practice Address - Country:US
Practice Address - Phone:614-440-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X, 261QP0904X
OHLPN.100395.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251K00000XAgenciesPublic Health or Welfare
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal