Provider Demographics
NPI:1366441099
Name:ROTH, JAYNE M (CNM)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 N COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3895
Mailing Address - Country:US
Mailing Address - Phone:419-291-3604
Mailing Address - Fax:419-479-6971
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-3604
Practice Address - Fax:419-479-6971
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08128176B00000X
OHNM-08128367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4691024Medicaid
OH000000358994OtherANTHEM
OH344428256053OtherCARESOURCE
OH2534887Medicaid
OH344428256OtherBEECHSTREET
MI4691033Medicaid
OH05225OtherPARAMOUNT
OH344428256OtherFRONTPATH
OH35263Medicare UPIN
OH75921Medicare PIN