Provider Demographics
NPI:1598886558
Name:ROTH, JEFFREY (PHD PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N JAMES ST
Mailing Address - Street 2:SUITES 104-106
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-3169
Mailing Address - Country:US
Mailing Address - Phone:302-633-0301
Mailing Address - Fax:302-633-0331
Practice Address - Street 1:240 N JAMES ST
Practice Address - Street 2:SUITES 104-106
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-3169
Practice Address - Country:US
Practice Address - Phone:302-633-0301
Practice Address - Fax:302-633-0331
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG02128T02Medicaid
DE0000342567Medicaid