Provider Demographics
NPI:1326080730
Name:ROTH, JACOB B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:B
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2110 PRIEST BRIDGE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2472
Mailing Address - Country:US
Mailing Address - Phone:301-858-9880
Mailing Address - Fax:410-721-2895
Practice Address - Street 1:2110 PRIEST BRIDGE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2472
Practice Address - Country:US
Practice Address - Phone:301-858-9880
Practice Address - Fax:410-721-2895
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD1194103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist