Provider Demographics
NPI:1134833197
Name:ROAN, JESSICA MARIE (RBT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:ROAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 NE 60 AVE
Mailing Address - Street 2:
Mailing Address - City:HOISINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67544-9228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1495 NE 60 AVE
Practice Address - Street 2:
Practice Address - City:HOISINGTON
Practice Address - State:KS
Practice Address - Zip Code:67544-9228
Practice Address - Country:US
Practice Address - Phone:785-817-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-08-4001106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician