Provider Demographics
NPI:1891045076
Name:ROTH, JACLYN MARIE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2790 CLAY EDWARDS DR STE 600
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3274
Mailing Address - Country:US
Mailing Address - Phone:816-691-5048
Mailing Address - Fax:816-346-7039
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 600
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3274
Practice Address - Country:US
Practice Address - Phone:816-691-5048
Practice Address - Fax:816-346-7039
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1048325133V00000X
MO2011016811133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered