Provider Demographics
NPI:1629682612
Name:ROTH, JEANA L (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JEANA
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 CRESCENT DR STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-3645
Mailing Address - Country:US
Mailing Address - Phone:636-489-4822
Mailing Address - Fax:
Practice Address - Street 1:4171 CRESCENT DR STE 202
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3645
Practice Address - Country:US
Practice Address - Phone:636-489-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018139123101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional