Provider Demographics
NPI:1871039990
Name:ROTH, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 MONUMENT ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2539
Mailing Address - Country:US
Mailing Address - Phone:310-367-3173
Mailing Address - Fax:
Practice Address - Street 1:1126 MONUMENT ST
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-2539
Practice Address - Country:US
Practice Address - Phone:310-367-3173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst