Provider Demographics
NPI:1477077303
Name:ROTH, JEANETTE MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 PRIMIVERA CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4869
Mailing Address - Country:US
Mailing Address - Phone:908-415-0895
Mailing Address - Fax:
Practice Address - Street 1:3901 WRIGHTSVILLE AVE STE 120
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6256
Practice Address - Country:US
Practice Address - Phone:910-679-8385
Practice Address - Fax:910-679-8385
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00494500235Z00000X
NC12318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist