Provider Demographics
NPI:1538361365
Name:ROE, JOHN ED JR (PHD, MA, MA)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ED
Last Name:ROE
Suffix:JR
Gender:M
Credentials:PHD, MA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 CAMERON PARK DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8480
Mailing Address - Country:US
Mailing Address - Phone:530-676-4445
Mailing Address - Fax:
Practice Address - Street 1:4120 CAMERON PARK DR
Practice Address - Street 2:SUITE 301
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8480
Practice Address - Country:US
Practice Address - Phone:530-676-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5769103T00000X
CAMFT 6551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL57690OtherPTAN, MEDICARE