Provider Demographics
NPI:1851615066
Name:ROTH, JAY EDWARD (CRNP)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:EDWARD
Last Name:ROTH
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 S 11TH ST
Mailing Address - Street 2:#3B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1968
Mailing Address - Country:US
Mailing Address - Phone:215-913-7381
Mailing Address - Fax:
Practice Address - Street 1:706 S 11TH ST
Practice Address - Street 2:#3B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1968
Practice Address - Country:US
Practice Address - Phone:215-913-7381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010741363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health