1295433662 NPI number — ROSHANDA SHAREE JACKSON EICHIE

Table of content: ROSHANDA SHAREE JACKSON EICHIE (NPI 1295433662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295433662 NPI number — ROSHANDA SHAREE JACKSON EICHIE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EICHIE
Provider First Name:
ROSHANDA
Provider Middle Name:
SHAREE JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EICHIE
Provider Other First Name:
ROSHANDA
Provider Other Middle Name:
JACKSON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AMFT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1295433662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92413-0115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-659-8632
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14393 PARK AVENUE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
442-327-9135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  129242 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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