Provider Demographics
NPI:1669693289
Name:ROGERS, JIM
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:ROGERS
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:P.O. BOX 1484
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-1484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26734 JORDAN RD.
Practice Address - Street 2:SUITE A-4
Practice Address - City:HELENDALE
Practice Address - State:CA
Practice Address - Zip Code:92342-1484
Practice Address - Country:US
Practice Address - Phone:760-961-6118
Practice Address - Fax:760-955-2242
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT35622106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist