Provider Demographics
NPI:1306381033
Name:ROTH, JENNIFER MICHELLE (LMHCA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:ROTH
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6544 FERGUSON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1178
Mailing Address - Country:US
Mailing Address - Phone:317-690-2941
Mailing Address - Fax:
Practice Address - Street 1:6544 FERGUSON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1178
Practice Address - Country:US
Practice Address - Phone:317-690-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN888000416A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health