Provider Demographics
NPI:1962804807
Name:ROVER, JAHMEL DIOR
Entity type:Individual
Prefix:
First Name:JAHMEL
Middle Name:DIOR
Last Name:ROVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N ARROWHEAD AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1148
Mailing Address - Country:US
Mailing Address - Phone:909-763-5800
Mailing Address - Fax:909-882-1282
Practice Address - Street 1:600 N ARROWHEAD AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1148
Practice Address - Country:US
Practice Address - Phone:909-763-5800
Practice Address - Fax:909-882-1282
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89947101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124100383Medicaid