Provider Demographics
NPI:1174254460
Name:ROTH, JENNIFER (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 N 4TH ST # 506
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-3712
Mailing Address - Country:US
Mailing Address - Phone:928-863-8354
Mailing Address - Fax:
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-863-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional