Provider Demographics
NPI:1295183440
Name:ROTH, JESSICA MARY (PHARMD, BCPS, BCGP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARY
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHARMD, BCPS, BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S BRYN MAWR AVE
Mailing Address - Street 2:1ST FLOOR INPATIENT PHARMACY
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3121
Mailing Address - Country:US
Mailing Address - Phone:484-337-3223
Mailing Address - Fax:
Practice Address - Street 1:9 STEARNS LANE HUGHES CENTER SOUTH GAH
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-3121
Practice Address - Country:US
Practice Address - Phone:570-214-0583
Practice Address - Fax:570-214-1523
Is Sole Proprietor?:No
Enumeration Date:2016-05-28
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP447818183500000X, 1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No183500000XPharmacy Service ProvidersPharmacist