Provider Demographics
NPI:1972228518
Name:ROTHENBERGER, JACKLYN ANN (MFT)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ANN
Last Name:ROTHENBERGER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9120 FISTERIS CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2112
Mailing Address - Country:US
Mailing Address - Phone:609-727-9257
Mailing Address - Fax:
Practice Address - Street 1:9120 FISTERIS CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-2112
Practice Address - Country:US
Practice Address - Phone:609-727-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT-358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty