Provider Demographics
NPI:1972304616
Name:ROACH, JENNIFER
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ROACH
Suffix:
Gender:
Credentials:
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:833 REMOUR LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9471
Mailing Address - Country:US
Mailing Address - Phone:530-925-6550
Mailing Address - Fax:
Practice Address - Street 1:833 REMOUR LN
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9471
Practice Address - Country:US
Practice Address - Phone:530-925-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA819436133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered