Provider Demographics
NPI:1760743108
Name:ROTH, JEFF GEORGE (MA LMHC)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:GEORGE
Last Name:ROTH
Suffix:
Gender:M
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 N 103RD ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9406
Mailing Address - Country:US
Mailing Address - Phone:206-354-5731
Mailing Address - Fax:
Practice Address - Street 1:21907 64TH AVE W STE 200
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6200
Practice Address - Country:US
Practice Address - Phone:206-319-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00009737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health