Provider Demographics
NPI:1992460737
Name:ROANE, JESSICA (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:ROANE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 S CRATER RD STE E
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9247
Mailing Address - Country:US
Mailing Address - Phone:804-731-6285
Mailing Address - Fax:
Practice Address - Street 1:3040 S CRATER RD STE E
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9247
Practice Address - Country:US
Practice Address - Phone:804-731-6285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007506103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical