Provider Demographics
NPI:1346647575
Name:ROTH, JENNIFER WYNN (LMT NMT CKTP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:WYNN
Last Name:ROTH
Suffix:
Gender:F
Credentials:LMT NMT CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 BROADWATER AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-4732
Mailing Address - Country:US
Mailing Address - Phone:406-696-6000
Mailing Address - Fax:
Practice Address - Street 1:2108 BROADWATER AVE STE 202
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-4732
Practice Address - Country:US
Practice Address - Phone:406-696-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT275225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist