Provider Demographics
NPI:1164777116
Name:ROTH, JILL DEBORAH (OD)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:DEBORAH
Last Name:ROTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:DEBORAH
Other - Last Name:LIECHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:980 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-1316
Mailing Address - Country:US
Mailing Address - Phone:260-824-2020
Mailing Address - Fax:260-824-4121
Practice Address - Street 1:980 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-1316
Practice Address - Country:US
Practice Address - Phone:260-824-2020
Practice Address - Fax:260-824-4121
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003754A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist