Basic Information
Provider Information | |||||||||
NPI: | 1467976993 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROACH | ||||||||
FirstName: | JODY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12201 BLUEGRASS PKWY | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402992361 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025687364 | ||||||||
FaxNumber: | 5025687136 | ||||||||
Practice Location | |||||||||
Address1: | 100 S WHITEWOMAN ST | ||||||||
Address2: |   | ||||||||
City: | COSHOCTON | ||||||||
State: | OH | ||||||||
PostalCode: | 438121068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7406221220 | ||||||||
FaxNumber: | 7406226384 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2017 | ||||||||
LastUpdateDate: | 12/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APRN.CNP021356 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | 0236769 | 05 | OH |   | MEDICAID | H605201 | 01 | OH | MEDICARE PTAN | OTHER |