Provider Demographics
NPI:1043451628
Name:ROTHSTEIN, JACK
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:ROTHSTEIN
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 1:27 E DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4201
Mailing Address - Country:US
Mailing Address - Phone:918-224-0225
Mailing Address - Fax:
Practice Address - Street 1:27 E DEWEY AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4201
Practice Address - Country:US
Practice Address - Phone:918-224-0225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)