Provider Demographics
NPI:1023334182
Name:ROTH, JENA ELIZABETH (BS)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:ELIZABETH
Last Name:ROTH
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SCHOOL ST
Mailing Address - Street 2:APT #5
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1745
Mailing Address - Country:US
Mailing Address - Phone:612-850-1066
Mailing Address - Fax:
Practice Address - Street 1:120 SCHOOL ST
Practice Address - Street 2:APT #5
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1745
Practice Address - Country:US
Practice Address - Phone:612-850-1066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist