Provider Demographics
NPI:1689057325
Name:ROTH, JENNIFER ISABEL (LIMHP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ISABEL
Last Name:ROTH
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 N LINCOLN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467-2444
Mailing Address - Country:US
Mailing Address - Phone:402-710-0564
Mailing Address - Fax:833-382-0104
Practice Address - Street 1:822 N LINCOLN AVE STE A
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467-2444
Practice Address - Country:US
Practice Address - Phone:402-710-0564
Practice Address - Fax:833-382-0104
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10547101YM0800X
NE2203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025173100Medicaid