Provider Demographics
NPI:1316139181
Name:ROACH, JACINDA B (RD)
Entity type:Individual
Prefix:MS
First Name:JACINDA
Middle Name:B
Last Name:ROACH
Suffix:
Gender:F
Credentials:RD
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Mailing Address - Street 1:1860 CHADWICK DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3463
Mailing Address - Country:US
Mailing Address - Phone:601-376-1681
Mailing Address - Fax:601-376-2491
Practice Address - Street 1:1860 CHADWICK DR
Practice Address - Street 2:SUITE 150
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3463
Practice Address - Country:US
Practice Address - Phone:601-376-1681
Practice Address - Fax:601-376-2491
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2010-03-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MSD1074133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I710006Medicare PIN